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Su G, Iwagami M, Qin X, McDonald H, Liu X, Carrero JJ, Stålsby Lundborg C, Nitsch D. Kidney disease and mortality in patients with respiratory tract infections: a systematic review and meta-analysis. Clin Kidney J 2021; 14:602-611. [PMID: 33623685 PMCID: PMC7886553 DOI: 10.1093/ckj/sfz188] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 11/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) are a common reason for people to seek medical care. RTIs are associated with high short-term mortality. Inconsistent evidence exists in the association between the presence of kidney disease and the risk of death in patient with RTIs. METHODS We searched the PubMed, Cochrane Library and Embase databases from inception through April 2019 for cohort and case-control studies investigating the presence of kidney disease (defined as medical diagnosis of kidney disease, reduced estimated glomerular filtration rate or creatinine clearance, elevated serum creatinine and proteinuria) on mortality in adults with RTIs in different settings including community, inpatient and intensive care units. We assessed the quality of the included studies using Cochrane Collaboration's tool and conducted a meta-analysis on the relative risk (RR) of death. RESULTS Of 5362 records identified, 18 studies involving 16 676 participants met the inclusion criteria, with 15 studies investigating pneumonia and 3 studies exploring influenza. The risk of bias in the available evidence was moderate. Most [17/18 (94.5%)] of studies reported positive associations of underlying chronic kidney disease with mortality. The pooled adjusted risk for all-cause mortality in patients with RTIs almost doubled [RR 1.96 (95% confidence interval 1.48-2.59)] in patients with kidney disease. Associations were consistent across different timings of kidney disease assessment and provenances of RTIs (community-acquired or healthcare-associated). CONCLUSIONS The presence of kidney disease is associated with higher mortality among people with RTIs, especially in those with pneumonia. The presence of kidney disease might be taken into account when considering admission for patients who present with RTIs.
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Affiliation(s)
- Guobin Su
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Department of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou City, China
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, China
- Health Systems and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Masao Iwagami
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Department of Health Services Research, University of Tsukuba, Ibaraki, Japan
| | - Xindong Qin
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Helen McDonald
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Xusheng Liu
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, Second Affiliated Hospital, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Stålsby Lundborg
- Health Systems and Policy, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Dorothea Nitsch
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Griesel R, Stewart A, van der Plas H, Sikhondze W, Mendelson M, Maartens G. Prognostic indicators in the World Health Organization's algorithm for seriously ill HIV-infected inpatients with suspected tuberculosis. AIDS Res Ther 2018; 15:5. [PMID: 29433509 PMCID: PMC5808414 DOI: 10.1186/s12981-018-0192-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/31/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Criteria for the 2007 WHO algorithm for diagnosing tuberculosis among HIV-infected seriously ill patients are the presence of one or more danger signs (respiratory rate > 30/min, heart rate > 120/min, temperature > 39 °C, and being unable to walk unaided) and cough ≥ 14 days. Determining predictors of poor outcomes among HIV-infected inpatients presenting with WHO danger signs could result in improved treatment and diagnostic algorithms. METHODS We conducted a prospective cohort study of inpatients presenting with any duration of cough and WHO danger signs to two regional hospitals in Cape Town, South Africa. The primary outcome was all-cause mortality up to 56 days post-discharge, and the secondary outcome a composite of any one of: hospital admission for > 7 days, died in hospital, transfer to a tertiary level or tuberculosis hospital. We first assessed the WHO danger signs as predictors of poor outcomes, then assessed the added value of other variables selected a priori for their ability to predict mortality in common respiratory opportunistic infections (CD4 count, body mass index (BMI), being on antiretroviral therapy (ART), hypotension, and confusion) by comparing the receiver operating characteristic (ROC) area under the curve (AUC) of the two multivariate models. RESULTS 484 participants were enrolled, median age 36, 66% women, 53% had tuberculosis confirmed on culture. The 56-day mortality was 13.2%. Inability to walk unaided, low BMI, low CD4 count, and being on ART were independently associated with poor outcomes. The multivariate model of the WHO danger signs showed a ROC AUC of 0.649 (95% CI 0.582-0.717) for predicting 56-day mortality, which improved to ROC AUC of 0.740 (95% CI 0.681-0.800; p = 0.004 for comparison between the two ROC AUCs) with the multivariate model including the a priori selected variables. Findings were similar in sub-analyses of participants with culture-positive tuberculosis and with cough duration ≥ 14 days. CONCLUSION The study design prevented a rigorous evaluation of the prognostic value of the WHO danger signs. Our prognostic model could result in improved algorithms, but needs to be validated.
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Affiliation(s)
- Rulan Griesel
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Annemie Stewart
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
| | - Helen van der Plas
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Welile Sikhondze
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, UCT Faculty of Health Sciences, Anzio Road, Observatory, Cape Town, 7925 South Africa
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Kiguradze T, Temps WH, Yarnold PR, Cashy J, Brannigan RE, Nardone B, Micali G, West DP, Belknap SM. Persistent erectile dysfunction in men exposed to the 5α-reductase inhibitors, finasteride, or dutasteride. PeerJ 2017; 5:e3020. [PMID: 28289563 PMCID: PMC5346286 DOI: 10.7717/peerj.3020] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 01/23/2017] [Indexed: 11/20/2022] Open
Abstract
Importance Case reports describe persistent erectile dysfunction (PED) associated with exposure to 5α-reductase inhibitors (5α-RIs). Clinical trial reports and the manufacturers’ full prescribing information (FPI) for finasteride and dutasteride state that risk of sexual adverse effects is not increased by longer duration of 5α-RI exposure and that sexual adverse effects of 5α-RIs resolve in men who discontinue exposure. Objective Our chief objective was to assess whether longer duration of 5α-RI exposure increases risk of PED, independent of age and other known risk factors. Men with shorter 5α-RI exposure served as a comparison control group for those with longer exposure. Design We used a single-group study design and classification tree analysis (CTA) to model PED (lasting ≥90 days after stopping 5α-RI). Covariates included subject attributes, diseases, and drug exposures associated with sexual dysfunction. Setting Our data source was the electronic medical record data repository for Northwestern Medicine. Subjects The analysis cohorts comprised all men exposed to finasteride or dutasteride or combination products containing one of these drugs, and the subgroup of men 16–42 years old and exposed to finasteride ≤1.25 mg/day. Main outcome and measures Our main outcome measure was diagnosis of PED beginning after first 5α-RI exposure, continuing for at least 90 days after stopping 5α-RI, and with contemporaneous treatment with a phosphodiesterase-5 inhibitor (PDE5I). Other outcome measures were erectile dysfunction (ED) and low libido. PED was determined by manual review of medical narratives for all subjects with ED. Risk of an adverse effect was expressed as number needed to harm (NNH). Results Among men with 5α-RI exposure, 167 of 11,909 (1.4%) developed PED (persistence median 1,348 days after stopping 5α-RI, interquartile range (IQR) 631.5–2320.5 days); the multivariable model predicting PED had four variables: prostate disease, duration of 5α-RI exposure, age, and nonsteroidal anti-inflammatory drug (NSAID) use. Of 530 men with new ED, 167 (31.5%) had new PED. Men without prostate disease who combined NSAID use with >208.5 days of 5α-RI exposure had 4.8-fold higher risk of PED than men with shorter exposure (NNH 59.8, all p < 0.002). Among men 16–42 years old and exposed to finasteride ≤1.25 mg/day, 34 of 4,284 (0.8%) developed PED (persistence median 1,534 days, IQR 651–2,351 days); the multivariable model predicting PED had one variable: duration of 5α-RI exposure. Of 103 young men with new ED, 34 (33%) had new PED. Young men with >205 days of finasteride exposure had 4.9-fold higher risk of PED (NNH 108.2, p < 0.004) than men with shorter exposure. Conclusion and relevance Risk of PED was higher in men with longer exposure to 5α-RIs. Among young men, longer exposure to finasteride posed a greater risk of PED than all other assessed risk factors.
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Affiliation(s)
- Tina Kiguradze
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - William H Temps
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | | | - John Cashy
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Robert E Brannigan
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Beatrice Nardone
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Giuseppe Micali
- Department of Dermatology, Faculty of Medicine and Surgery, University of Catania, Catania, Italy
| | - Dennis Paul West
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Steven M Belknap
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Department of Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Millman AJ, Greenbaum A, Walaza S, Cohen AL, Groome MJ, Reed C, McMorrow M, Tempia S, Venter M, Treurnicht FK, Madhi SA, Cohen C, Variava E. Development of a respiratory severity score for hospitalized adults in a high HIV-prevalence setting-South Africa, 2010-2011. BMC Pulm Med 2017; 17:28. [PMID: 28148246 PMCID: PMC5288997 DOI: 10.1186/s12890-017-0368-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 01/18/2017] [Indexed: 11/29/2022] Open
Abstract
Background Acute lower respiratory tract infections (LRTI) are a frequent cause of hospitalization and mortality in South Africa; however, existing respiratory severity scores may underestimate mortality risk in HIV-infected adults in resource limited settings. A simple predictive clinical score for low-resource settings could aid healthcare providers in the management of patients hospitalized with LRTI. Methods We analyzed 1,356 LRTI hospitalizations in adults aged ≥18 years enrolled in Severe Acute Respiratory Illness (SARI) surveillance in three South African hospitals from January 2010 to December 2011. Using demographic and clinical data at admission, we evaluated potential risk factors for in-hospital mortality. We evaluated three existing respiratory severity scores, CURB-65, CRB-65, and Classification Tree Analysis (CTA) Score assessing for discrimination and calibration. We then developed a new respiratory severity score using a multivariable logistic regression model for in-hospital mortality and assigned points to risk factors based on the coefficients in the multivariable model. Finally we evaluated the model statistically using bootstrap resampling techniques. Results Of the 1,356 patients hospitalized with LRTI, 101 (7.4%) died while hospitalized. The CURB-65, CRB-65, and CTA scores had poor calibration and demonstrated low discrimination with c-statistics of 0.594, 0.548, and 0.569 respectively. Significant risk factors for in-hospital mortality included age ≥ 45 years (A), confusion on admission (C), HIV-infection (H), and serum blood urea nitrogen >7 mmol/L (U), which were used to create the seven-point ACHU clinical predictor score. In-hospital mortality, stratified by ACHU score was: score ≤1, 2.4%, score 2, 6.4%, score 3, 11.9%, and score ≥ 4, 29.3%. Final models showed good discrimination (c-statistic 0.789) and calibration (chi-square 1.6, Hosmer-Lemeshow goodness-of-fit p-value = 0.904) and discriminated well in the bootstrap sample (average optimism of 0.003). Conclusions Existing clinical predictive scores underestimated mortality in a low resource setting with a high HIV burden. The ACHU score incorporates a simple set a risk factors that can accurately stratify patients ≥18 years of age with LRTI by in-hospital mortality risk. This score can quantify in-hospital mortality risk in an HIV-endemic, resource-limited setting with limited clinical information and if used to facilitate timely treatment may improve clinical outcomes. Electronic supplementary material The online version of this article (doi:10.1186/s12890-017-0368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexander J Millman
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA. .,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Adena Greenbaum
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA.,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Sibongile Walaza
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Adam L Cohen
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA.,Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa
| | - Michelle J Groome
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Carrie Reed
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - Meredith McMorrow
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA
| | - Stefano Tempia
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA, 30329, USA.,Influenza Program, Centers for Disease Control and Prevention, Pretoria, South Africa.,Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Marietjie Venter
- Global Disease Detection Center, Division of Global Health Protection, Centers for Disease Control and Prevention, Pretoria, South Africa.,Zoonoses Research Program, Department of Medical Virology, University of Pretoria, Pretoria, South Africa
| | - Florette K Treurnicht
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Shabir A Madhi
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,Medical Research Council, Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ebrahim Variava
- Department of Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa.,Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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5
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Koss CA, Jarlsberg LG, den Boon S, Cattamanchi A, Davis JL, Worodria W, Ayakaka I, Sanyu I, Huang L. A Clinical Predictor Score for 30-Day Mortality among HIV-Infected Adults Hospitalized with Pneumonia in Uganda. PLoS One 2015; 10:e0126591. [PMID: 25962069 PMCID: PMC4427329 DOI: 10.1371/journal.pone.0126591] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 04/05/2015] [Indexed: 12/02/2022] Open
Abstract
Background Pneumonia is a major cause of mortality among HIV-infected patients. Pneumonia severity scores are promising tools to assist clinicians in predicting patients’ 30-day mortality, but existing scores were developed in populations infected with neither HIV nor tuberculosis (TB) and include laboratory data that may not be available in resource-limited settings. The objective of this study was to develop a score to predict mortality in HIV-infected adults with pneumonia in TB-endemic, resource-limited settings. Methods We conducted a secondary analysis of data from a prospective study enrolling HIV-infected adults with cough ≥2 weeks and <6 months and clinically suspected pneumonia admitted to Mulago Hospital in Kampala, Uganda from September 2008 to March 2011. Patients provided two sputum specimens for mycobacteria, and those with Ziehl-Neelsen sputum smears that were negative for mycobacteria underwent bronchoscopy with inspection for Kaposi sarcoma and testing for mycobacteria and fungi, including Pneumocystis jirovecii. A multivariable best subsets regression model was developed, and one point was assigned to each variable in the model to develop a clinical predictor score for 30-day mortality. Results Overall, 835 patients were studied (mean age 34 years, 53.4% female, 30-day mortality 18.2%). A four-point clinical predictor score was identified and included heart rate >120 beats/minute, respiratory rate >30 breaths/minute, oxygen saturation <90%, and CD4 cell count <50 cells/mm3. Patients’ 30-day mortality, stratified by score, was: score 0 or 1, 12.6%, score 2 or 3, 23.4%, score 4, 53.9%. For each 1 point change in clinical predictor score, the odds of 30-day mortality increased by 65% (OR 1.65, 95% CI 1.39-1.96, p <0.001). Conclusions A simple, four-point scoring system can stratify patients by levels of risk for mortality. Rapid identification of higher risk patients combined with provision of timely and appropriate treatment may improve clinical outcomes. This predictor score should be validated in other resource-limited settings.
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Affiliation(s)
- Catherine A. Koss
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- * E-mail:
| | - Leah G. Jarlsberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Saskia den Boon
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
| | - Adithya Cattamanchi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
| | - J. Lucian Davis
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
| | - William Worodria
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Department of Medicine, Mulago National Referral and Teaching Hospital, Kampala, Uganda
| | - Irene Ayakaka
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
| | - Ingvar Sanyu
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
| | - Laurence Huang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Makerere University–University of California San Francisco Research Collaboration, Kampala, Uganda
- HIV/AIDS Division, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
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Bao Z, Rong X, Cheng Q, Zhou M, Gong Q, Shi G, Wan H. Clinical and microbiological characteristics of community-acquired pneumonia in human immunodeficiency virus-infected patients: a retrospective analysis of 79 HIV/AIDS patients. CLINICAL RESPIRATORY JOURNAL 2014; 8:255-61. [PMID: 23577954 DOI: 10.1111/crj.12024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 04/29/2013] [Accepted: 04/07/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Zhiyao Bao
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Xiajun Rong
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Qijian Cheng
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Min Zhou
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Qiming Gong
- Department of Infectious Diseases; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Guochao Shi
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
| | - Huanying Wan
- Department of Pulmonary Medicine; Ruijin Hospital; Shanghai Jiao Tong University; Shanghai China
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Chew KW, Yen IH, Li JZ, Winston LG. Predictors of pneumonia severity in HIV-infected adults admitted to an Urban public hospital. AIDS Patient Care STDS 2011; 25:273-7. [PMID: 21488749 DOI: 10.1089/apc.2010.0365] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Data on outcomes of community-acquired pneumonia (CAP) in the HIV-infected population are mixed and the perception of worse outcomes in HIV may lead to excess hospitalization. We retrospectively evaluated the utility of the Pneumonia Severity Index, or PORT score, as a prediction rule for mortality in 102 HIV-infected adults hospitalized at an urban public hospital with CAP. Primary outcome was survival at 30 days. Secondary outcomes included survival on discharge, intensive care unit (ICU) admission, length of stay, and readmission within 30 days. The cohort was predominantly male (70%) with a mean age of 45.4 years (standard deviation [SD] ± 7.4). Mean CD4 cell count was 318 cells per microliter; 40 (39%) had CD4 less than 200 cells per microliter. Forty-three percent were on antiretroviral therapy at the time of admission and 31% on prophylactic antibiotics. Twelve patients had bacteremia on admission, predominantly with Streptococcus pneumoniae. Of the 46 patients with admission sputum cultures, 20 yielded an organism, most commonly Haemophilus influenzae and S. pneumoniae. Overall survival in the cohort was high, 96%. Most patients (81%) had a low PORT risk score (class I-III). PORT score predicted 30-day survival (p=0.01) and ICU admission (p=0.03), but antiretroviral use did not. In contrast to a prior study, we did not find that CD4 cell count predicted CAP outcome. Lack of stable housing was not associated with worse outcomes. The PORT score may be a valid tool to predict mortality and need for hospital admission in HIV-infected patients with CAP.
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Affiliation(s)
- Kara W. Chew
- Division of Infectious Diseases, Department of Medicine, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, California
| | - Irene H. Yen
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Jonathan Z. Li
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lisa G. Winston
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, San Francisco, California
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8
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Madeddu G, Porqueddu EM, Cambosu F, Saba F, Fois AG, Pirina P, Mura MS. Bacterial Community Acquired Pneumonia in HIV-Infected Inpatients in the Highly Active Antiretroviral Therapy Era. Infection 2008; 36:231-6. [DOI: 10.1007/s15010-007-7162-0] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Accepted: 10/24/2007] [Indexed: 11/29/2022]
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9
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Nebeker JR, Yarnold PR, Soltysik RC, Sauer BC, Sims SA, Samore MH, Rupper RW, Swanson KM, Savitz LA, Shinogle J, Xu W. Developing Indicators of Inpatient Adverse Drug Events Through Nonlinear Analysis Using Administrative Data. Med Care 2007; 45:S81-8. [PMID: 17909388 DOI: 10.1097/mlr.0b013e3180616c2c] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Because of uniform availability, hospital administrative data are appealing for surveillance of adverse drug events (ADEs). Expert-generated surveillance rules that rely on the presence of International Classification of Diseases, 9th Revision Clinical Modification (ICD-9-CM) codes have limited accuracy. Rules based on nonlinear associations among all types of available administrative data may be more accurate. OBJECTIVES By applying hierarchically optimal classification tree analysis (HOCTA) to administrative data, derive and validate surveillance rules for bleeding/anticoagulation problems and delirium/psychosis. RESEARCH DESIGN Retrospective cohort design. SUBJECTS A random sample of 3987 admissions drawn from all 41 Utah acute-care hospitals in 2001 and 2003. MEASURES Professional nurse reviewers identified ADEs using implicit chart review. Pharmacists assigned Medical Dictionary for Regulatory Activities codes to ADE descriptions for identification of clinical groups of events. Hospitals provided patient demographic, admission, and ICD9-CM data. RESULTS Incidence proportions were 0.8% for drug-induced bleeding/anticoagulation problems and 1.0% for drug-induced delirium/psychosis. The model for bleeding had very good discrimination and sensitivity at 0.87 and 86% and fair positive predictive value (PPV) at 12%. The model for delirium had excellent sensitivity at 94%, good discrimination at 0.83, but low PPV at 3%. Poisoning and adverse event codes designed for the targeted ADEs had low sensitivities and, when forced in, degraded model accuracy. CONCLUSIONS Hierarchically optimal classification tree analysis is a promising method for rapidly developing clinically meaningful surveillance rules for administrative data. The resultant model for drug-induced bleeding and anticoagulation problems may be useful for retrospective ADE screening and rate estimation.
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Affiliation(s)
- Jonathan R Nebeker
- VA Salt Lake City Geriatrics, Research, Education, and Clinical Center (GRECC, Salt Lake City, Utah, USA.
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10
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Abstract
BACKGROUND The pneumonia severity index (PSI) accounts for many comorbidities, but not immunosuppression. OBJECTIVES To document the utility of the PSI to predict mortality in immunocompromised patients (IP) with community-acquired pneumonia (CAP). METHODS Charts of 284 patients with immunosuppression and CAP were reviewed, and these patients were compared with a contemporary sample of non-IP with CAP. The ability of the PSI to predict mortality was assessed by using multiple logistic regression. Discrimination of the PSI was studied by using the concordance index. RESULTS Thirty-nine of 284 IP died. Mortality varied according to the etiology of the immunosuppression. Patients with HIV, solid organ transplantation or treatment with immunosuppressive drugs (n=118) had a low in-hospital mortality (4.3%) and were classified as low risk. IP with hematological malignancies, chemotherapy, chest radiation or marrow transplantation (n=166) had a high mortality (20%) and were classified as high risk. Compared with non-IP, low-risk IP had similar PSI-controlled mortality (OR=0.9, P=0.80), whereas high-risk IP had significantly greater mortality (OR=2.8, P<0.0001). The concordance index revealed similar discrimination for the PSI in low-risk IP (0.77) and in non-IP (0.7), but inferior discrimination in high-risk patients (0.6). CONCLUSIONS Patients with CAP and immunosuppression can be divided into low-risk and high-risk groups. The low-risk IP have mortality similar to non-IP and can be risk stratified by using the PSI.
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Affiliation(s)
| | | | - Charles KN Chan
- Correspondence: Dr Charles KN Chan, Toronto General Hospital, Room 9N945, 585 University Avenue, Toronto, Ontario M5G 2C4. Telephone 416-340-3235, fax 416-971-6427, e-mail
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Arozullah AM, Lee SYD, Khan T, Kurup S, Ryan J, Bonner M, Soltysik R, Yarnold PR. The roles of low literacy and social support in predicting the preventability of hospital admission. J Gen Intern Med 2006; 21:140-5. [PMID: 16336616 PMCID: PMC1484663 DOI: 10.1111/j.1525-1497.2005.00300.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prior studies found higher hospitalization rates among patients with low literacy, but did not determine the preventability of these admissions or consider other determinants of hospitalization, such as social support. This study evaluated whether low literacy was a predictor for preventability of hospitalization when considered in the context of social support, sociodemographics, health status, and risk behaviors. METHODS A convenience sample of 400 patients, admitted to general medicine wards in a university-affiliated Veterans Affairs hospital between August 1, 2001 and April 1, 2003, completed a face-to-face interview to assess literacy, sociodemographics, social support, health status, and risk behaviors. Two Board-certified Internists independently assessed preventability of hospitalization and determined the primary preventable cause through blinded medical chart reviews. RESULTS Neither low literacy (<seventh grade) nor very low literacy (<fourth grade) was significantly associated with preventability of hospitalization. In multivariable analysis, significant predictors of having a preventable cause of hospitalization included binge alcohol drinking (P< or =.001), lower social support for medical care (P<.04), < or =3 annual clinic visits (P<.005), and > or =12 people talked to weekly (P<.023). Among nonbinge drinkers with lower social support for medical care, larger social networks were predictive of preventability of hospitalization. Among nonbinge drinkers with higher support for medical care, lower outpatient utilization was predictive of the preventability of hospitalization. CONCLUSIONS While low literacy was not predictive of admission preventability, the formal assessment of alcohol binge drinking, social support for medical care, social network size, and prior outpatient utilization may enhance our ability to predict the preventability of hospitalizations and develop targeted interventions.
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12
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Abstract
PURPOSE OF REVIEW Pneumonia occurs commonly in HIV-infected patients and this review highlights some of the recent findings in the epidemiology, pathogenesis, clinical features, treatment and prevention of this condition. RECENT FINDINGS Pneumonia remains an important cause of morbidity and mortality in HIV-infected patients. A number of factors have been identified that increase the risk of pneumonia. Cigarette smoking increases the risk of lung colonization, as well acute pneumonia due to Pneumocystis jiroveci, and has been documented to produce significant depression of the phagocytic function of alveolar macrophages in HIV-infected patients, which may underlie this risk. Legionella pneumophila infections appear to be uncommon in HIV-infected patients, while pneumonia with Streptococcus pneumoniae continues to occur with regularity, including infections with antibiotic-resistant isolates. Pneumocystis pneumonia occurs with a low incidence in patients receiving HAART, once the CD4 count increases to over 200 microl. Studies of invasive pneumococcal infections (predominantly pneumonia) indicate that in critically ill cases, including HIV-seropositive patients, combination antibiotic therapy is associated with a lower mortality than monotherapy. The 23-polyvalent pneumococcal vaccine has been shown to reduce the risk of pneumococcal infection in HIV-infected adults receiving HAART, and a 9-valent conjugate pneumococcal vaccine has been shown to reduce the incidence of radiologically confirmed pneumonia in HIV-seropositive and HIV-seronegative children. SUMMARY Pneumonia remains an important condition in HIV-infected patients, but recent studies demonstrate that antibiotic prophylaxis, the introduction of HAART, recognition of specific risk factors, new antibiotic treatment strategies and effective vaccines should serve to decrease its impact.
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Affiliation(s)
- Charles Feldman
- Division of Pulmonology, Department of Medicine, Johannesburg Hospital and University of the Witwatersrand, Johannesburg, South Africa.
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13
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Miller CD, Lindsell CJ, Anantharaman V, Lim SH, Greenway J, Pollack CV, Tiffany BR, Hollander JE, Gibler WB, Hoekstra JW. Performance of a population-based cardiac risk stratification tool in Asian patients with chest pain. Acad Emerg Med 2005; 12:423-30. [PMID: 15863398 DOI: 10.1197/j.aem.2004.11.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Most contemporary cardiac risk stratification tools have been derived and validated in mixed-race populations. Their validity in single-race populations has not been tested. The authors sought to compare the performance of a risk stratification tool between a mixed-race U.S. patient population and an Asian patient population. METHODS This study is an analysis of data from the Internet Tracking Registry for Acute Coronary Syndromes (i(*)trACS) registry of patients with chest pain presenting to the emergency departments of eight U.S. centers and one site in Singapore. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) was computed for included patients, and its performance in predicting acute coronary syndrome (ACS) was compared between patients from the United States and Singapore. RESULTS Of the 11,991 included patients, 1,120 experienced ACS. Although the ACI-TIPI demonstrated similar accuracy among groups (area under the curve, 0.729 [U.S.] vs. 0.719 [Singapore]; p = 0.5611), sensitivity and specificity were different when equal ACI-TIPI thresholds were considered. Recreating the logistic regression models used to create the ACI-TIPI showed similar results between the derived parameters and the parameters estimated for the U.S. group. In contrast, age older than 50 years (log-odds ratio [LOR], 0.107; 95% confidence interval [CI] = 0.518 to 0.713), male gender (LOR, 0.487; 95% CI = 0.149 to 1.122), and chest pain as a primary complaint (LOR, 0.237; 95% CI = 0.139 to 0.613) had little predictive power in patients from Singapore. CONCLUSIONS Differences exist in presentation and factors associated with ACS among patients from the United States and Singapore that may affect the performance of risk stratification tools. These findings suggest that cardiac clinical decision rules need international validation.
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Affiliation(s)
- Chadwick D Miller
- Department of Emergency Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston Salem, NC 27157-1089, USA.
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14
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Lim WS, Macfarlane JT. Importance of severity of illness assessment in management of lower respiratory infections. Curr Opin Infect Dis 2004; 17:121-5. [PMID: 15021051 DOI: 10.1097/00001432-200404000-00009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Patients with lower respiratory infections display a wide spectrum of disease severity. Management decisions regarding site of care, extent of investigations and level of treatment are mainly based on disease severity. Several severity assessment tools are still undergoing evaluation. This review highlights recent relevant studies. RECENT FINDINGS Severity prediction rules such as the Pneumonia Severity Index cannot be relied upon as the sole means of identifying patients with lower respiratory infections who do not need hospital admission. Up to 40% of patients assigned to low-risk groups may require hospitalization. The most common medical reason for hospitalization in these circumstances is the presence of unstable comorbid illness. Social factors are equally important in the decision to admit. A new prediction rule based on the British Thoracic Society prediction rule has been proposed. This divides patients with community acquired pneumonia into three management groups based on risk of mortality. A prediction rule for use in patients with HIV-associated community acquired pneumonia has also been proposed. An IL-10 polymorphism has been identified as a prognostic factor in community acquired pneumonia. Audits examining the impact of adherence to severity-based guidelines on the outcome of community acquired pneumonia have revealed conflicting results. Differences in outcome may only be significant for patients with the most severe illness. SUMMARY Severity of illness assessment is important in guiding management options at various stages in the clinical course of lower respiratory infections. However, no prediction rule should supercede clinical judgment.
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Affiliation(s)
- Wei Shen Lim
- Department of Respiratory Medicine, David Evans Research Centre, Nottingham City Hospital, Nottingham, UK.
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15
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Uphold CR, Deloria-Knoll M, Palella FJ, Parada JP, Chmiel JS, Phan L, Bennett CL. US hospital care for patients with HIV infection and pneumonia: the role of public, private, and Veterans Affairs hospitals in the early highly active antiretroviral therapy era. Chest 2004; 125:548-56. [PMID: 14769737 DOI: 10.1378/chest.125.2.548] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES We evaluated differences in processes and outcomes of HIV-related pneumonia care among patients in Veterans Affairs (VA), public, and for-profit and not-for-profit private hospitals in the United States. We compared the results of our current study (1995 to 1997) with those of our previous study that included a sample of patients receiving care during the years 1987 to 1990 to determine how HIV-related pneumonia care had evolved over the last decade. SETTING/PATIENTS The sample consisted of 1,231 patients with HIV infection who received care for Pneumocystis carinii pneumonia (PCP) and 750 patients with HIV infection who received care for community-acquired pneumonia (CAP) during the years 1995 to 1997. MEASUREMENT We conducted a retrospective medical record review and evaluated patient and hospital characteristics, HIV-related processes of care (timely use of anti-PCP medications, adjunctive corticosteroids), non-HIV-related processes of care (timely use of CAP treatment medications, diagnostic testing, ICU utilization, rates of endotracheal ventilation, placement on respiratory isolation), length of inpatient hospital stay, and inpatient mortality. RESULTS Rates of timely use of antibiotics and adjunctive corticosteroids for treating PCP were high and improved dramatically from the prior decade. However, compliance with consensus guidelines that recommend < 8 h as the optimal time window for initiation of antibiotics to treat CAP was lower. For both PCP and CAP, variations in processes of care and lengths of in-hospital stays, but not mortality rates, were noted at VA, public, private not-for-profit hospitals, and for-profit hospitals. CONCLUSIONS This study provides the first overview of HIV-related pneumonia care in the early highly active antiretroviral therapy era, and contrasts current findings with those of a similarly conducted study from a decade earlier. Quality of care for patients with PCP improved, but further efforts are needed to facilitate the appropriate management of CAP. In the third decade of the epidemic, it will be important to monitor whether variations in processes of care for various HIV-related clinical diagnoses among different types of hospitals persist.
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MESH Headings
- AIDS-Related Opportunistic Infections/diagnosis
- AIDS-Related Opportunistic Infections/drug therapy
- AIDS-Related Opportunistic Infections/mortality
- Adult
- Antiretroviral Therapy, Highly Active/methods
- Community-Acquired Infections/diagnosis
- Community-Acquired Infections/drug therapy
- Community-Acquired Infections/mortality
- Female
- HIV Infections/diagnosis
- HIV Infections/drug therapy
- HIV Infections/mortality
- Health Care Surveys
- Hospital Mortality/trends
- Hospitalization/statistics & numerical data
- Hospitals, Private/standards
- Hospitals, Private/statistics & numerical data
- Hospitals, Public/standards
- Hospitals, Public/statistics & numerical data
- Hospitals, Veterans/standards
- Hospitals, Veterans/statistics & numerical data
- Humans
- Male
- Middle Aged
- Outcome and Process Assessment, Health Care
- Pneumonia, Pneumocystis/diagnosis
- Pneumonia, Pneumocystis/drug therapy
- Pneumonia, Pneumocystis/mortality
- Probability
- Retrospective Studies
- Statistics, Nonparametric
- United States/epidemiology
- United States Department of Veterans Affairs
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Affiliation(s)
- Constance R Uphold
- Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System, Research Department, Stop 151, 1601 SW Archer Road, Gainesville, FL 32608-1197, USA.
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16
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Sureka A, Parada JP, Deloria-Knoll M, Chmiel JS, Phan L, Lyons TM, Ali S, Yarnold PR, Weinstein RA, Dehovitz JA, Jacobson JM, Goetz MB, Campo RE, Berland D, Bennett CL, Uphold CR. HIV-related pneumonia care in older patients hospitalized in the early HAART era. AIDS Patient Care STDS 2004; 18:99-107. [PMID: 15006184 DOI: 10.1089/108729104322802524] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Age-related variations in care have been identified for HIV-associated Pneumocystis carinii pneumonia (PCP) in both the 1980s and 1990s. We evaluated if age-related variations affected all aspects of HIV-specific and non-HIV-specific care for HIV-infected individuals with PCP or community-acquired pneumonia (CAP), or whether age-related variations were primarily limited to HIV-specific aspects of care. Subjects were HIV-infected persons with PCP (n = 1855) or CAP (n = 1415) hospitalized in 8 cities from 1995 to 1997. Nine percent of our study patients had received protease inhibitors and 39% had received any type of antiretroviral therapy prior to hospitalization. Data were abstracted from medical records and included severity of illness, HIV-specific aspects of care (initiation of PCP medications), general measures of care [initiation of CAP medications, intubation, and intensive care units (ICU)], and inpatient mortality. Compared to younger patients, pneumonia patients 50 years of age or older were significantly more likely to: be severely ill (PCP, 20.4% vs. 10.4%; CAP, 27.5% vs. 14.9%; each p = 0.001), receive ICU care (PCP, 22.0% vs. 12.8%, p = 0.002; CAP: 15.1% vs. 9.4%; p = 0.02), and be intubated (PCP, 14.6% vs. 8.4%, p = 0.01; CAP, 9.9% vs. 5.6%, p = 0.03). Compared to younger patients, older patients (>/=50 years) had similar rates of timely medications for CAP (48.5% vs. 50.8%) but had lower rates of receiving anti-PCP medications (85.8% vs. 92.9%, p = 0.002). Differences by age in timely initiation of PCP medications, ICU use, and intubation were limited to the nonseverely ill patients. Older hospitalized patients were more likely to die (PCP, 18.3% vs. 10.4%; CAP, 13.4% vs. 8.5%; each p < 0.05). After adjustment for disease severity and timeliness of antibiotic use, mortality rates were similar for both age groups. Physicians should develop strategies that increase awareness of the possibility of HIV infection in older individuals.
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Affiliation(s)
- Ashish Sureka
- Buehler Center on Aging, Northwestern University Medical School, Chicago, Illinois, USA
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Viale P, Scudeller L, Petrosillo N, Girardi E, Cadeo B, Signorini L, Pagani L, Carosi G. Clinical Stability in Human Immunodeficiency Virus–Infected Patients with Community‐Acquired Pneumonia. Clin Infect Dis 2004; 38:271-9. [PMID: 14699461 DOI: 10.1086/380788] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2003] [Accepted: 09/05/2003] [Indexed: 11/03/2022] Open
Abstract
Clinical stability (CS), defined as normalization of vital signs, is often used to manage inpatients with community-acquired pneumonia (CAP). The main objective of our study was to identify a reliable definition of CS for human immunodeficiency virus (HIV)-positive patients with CAP. During an 18-month period, 437 HIV-positive Italian inpatients with CAP were enrolled in the study. We used 3 definitions of CS (from a less conservative [definition 1] to a more conservative [definition 3] definition) based on combinations of different thresholds for vital signs. Assessments were performed at admission and daily during the hospital stay. For the 3 definitions, 14.9%, 8.0%, and 4.8% of patients were stable at baseline, with deterioration after reaching CS in 7.16%, 4.76%, and 2.05%, respectively. The 8 patients whose conditions deteriorated after reaching CS definition 3 (systolic blood pressure, >90 mm Hg; pulse, <90 beats/min; respiratory rate, <20 breaths/min; oxygen saturation, >90%; temperature, <37 degrees C; ability to eat; and normal mental status) survived and were discharged from the hospital. The more conservative definition of CS appears to be reliable for the management of HIV-infected patients with CAP.
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Affiliation(s)
- P Viale
- Clinic of Infectious Disease, Department of Clinical and Morphological Research, School of Medicine, University of Udine, Udine, Italy.
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