Management and documentation of pneumonia - a comparison of patients consulting primary care and emergency care

OBJECTIVE

To compare management and documentation of vital signs, symptoms and infection severity in pneumonia patients seeking primary care and emergency care without referral.

DESIGN

Medical record review of vital signs, examination findings and severity of pneumonia.

SETTING

Primary and emergency care.

SUBJECTS

Two hundred and forty patients diagnosed with pneumonia.

MAIN OUTCOME MEASURES

Vital signs, examination findings and severity of pneumonia. Assessments of pneumonia severity according to the reviewers, the traffic light score and CRB-65.

RESULTS

Respiratory rate, blood pressure, heart rate and oxygen saturation were less often documented in primary care (p < .001). Chest X-ray was performed in 5% of primary care patients vs. 88% of emergency care patients (p < .01). Primary care patients had longer symptom duration, higher oxygen saturation and lower respiratory rate. In total, the reviewers assessed 63% of all pneumonias as mild and 9% as severe. The traffic light scoring model identified 11 patients (9%) in primary care and 53 patients (44%) in emergency care at high risk of severe infection.

CONCLUSIONS

Vital signs were documented less often in primary care than in emergency care. Patients in primary care appear to have a less severe pneumonia, indicating attendance to the correct care level. The traffic light scoring model identified more patients at risk of severe infection than CRB-65, where the parameters were documented to a limited extent.

Effect of high-frequency repetitive transcranial magnetic stimulation on swallowing function and pneumonia in poststroke dysphagia in rats

BACKGROUND

Post-stroke dysphagia (PSD) is a common symptom of stroke. Clinical complications of PSD include malnutrition and pneumonia. Clinical studies have shown that high-frequency repetitive transcranial magnetic stimulation (HF-rTMS) can improve the swallowing function in stroke patients. However, few studies have elucidated the underlying molecular mechanisms.

METHODS

A PSD rat model was established using transient middle cerebral artery occlusion (tMCAO). Rats were randomly divided into sham-operated groups, PSD groups, PSD + sham-rTMS groups, PSD + 5 Hz-rTMS groups, PSD + 10 Hz-rTMS groups and PSD + 20 Hz-rTMS groups. Rats were weighed and videofluoroscopic swallowing studies were conducted. Pulmonary inflammation, levels of substance P (SP) and calcitonin gene-related peptide (CGRP) in the serum, lung, and nucleus tractus solitarius (NTS), brain-derived neurotrophic factor (BDNF) and 5-hydroxytryptamine (5HT) in NTS were evaluated.

RESULTS

Rats in the PSD group experienced weight loss, reduced bolus area and pharyngeal bolus speed, and increased pharyngeal transit time (PTT) and inter-swallow interval (ISI) on day 7 and day 14 after operation. Moreover, PSD rats showed pulmonary inflammation, reduced levels of SP in the lung and serum, increased levels of CGRP in the lung and NTS, reduced levels of BDNF and 5HT in the NTS. There was no significant difference between the PSD group and the PSD + sham-rTMS group in the results of weight and VFSS. Comparing with the PSD group, there significant increases in the bolus area, decreases in PTT of rats following 5 Hz rTMS intervention. HF-rTMS at 10 Hz significantly increased the weight, bolus area, pharyngeal bolus speed and decreased the PTT and ISI of rats. There were also significant increases in the bolus area (p < 0.01) and pharyngeal bolus speed, decreases in PTT and ISI of rats following 20 Hz rTMS intervention. Furthermore, compared with the PSD + 5 Hz-rTMS group, there were significant increases in the bolus area and pharyngeal bolus speed, decreases in ISI in the swallowing function of rats in the PSD + 10 Hz-rTMS group. Besides, compared with the PSD + 5 Hz-rTMS group, there were significant decreases in ISI in the swallowing function of rats in the PSD + 20 Hz-rTMS group. HF-rTMS at 10 Hz alleviated pulmonary inflammation, increased the levels of SP in the lung, serum, and NTS, CGRP in the serum and NTS, 5HT in the NTS of PSD rats.

CONCLUSION

Compared with 5 Hz and 20 Hz rTMS, 10 Hz rTMS more effectively improved the swallowing function of rats with PSD. HF-rTMS at 10 Hz improved the swallowing function and alleviated pneumonia in PSD rats. The mechanism may be related to increased levels of SP in the lung, serum and NTS, levels of CGRP in the serum and NTS, 5HT in the NTS after HF-rTMS treatment.

Optimizing Diagnosis and Management of Community-acquired Pneumonia in the Emergency Department

Pneumonia is split into 3 diagnostic categories: community-acquired pneumonia (CAP), health care-associated pneumonia, and ventilator-associated pneumonia. This classification scheme is driven not only by the location of infection onset but also by the predominant associated causal microorganisms. Pneumonia is diagnosed in over 1.5 million US emergency department visits annually (1.2% of all visits), and most pneumonia diagnosed by emergency physicians is CAP.

Artificial intelligence for the optimal management of community-acquired pneumonia

PURPOSE OF REVIEW

This timely review explores the integration of artificial intelligence (AI) into community-acquired pneumonia (CAP) management, emphasizing its relevance in predicting the risk of hospitalization. With CAP remaining a global public health concern, the review highlights the need for efficient and reliable AI tools to optimize resource allocation and improve patient outcomes.

RECENT FINDINGS

Challenges in CAP management delve into the application of AI in predicting CAP-related hospitalization risks, and complications, and mortality. The integration of AI-based risk scores in managing CAP has the potential to enhance the accuracy of predicting patients at higher risk, facilitating timely intervention and resource allocation. Moreover, AI algorithms reduce variability associated with subjective clinical judgment, promoting consistency in decision-making, and provide real-time risk assessments, aiding in the dynamic management of patients with CAP.

SUMMARY

The development and implementation of AI-tools for hospitalization in CAP represent a transformative approach to improving patient outcomes. The integration of AI into healthcare has the potential to revolutionize the way we identify and manage individuals at risk of severe outcomes, ultimately leading to more efficient resource utilization and better overall patient care.

Factors associated with intubation in patients with acute hypoxaemic respiratory failure treated with high-flow nasal cannula oxygen therapy: A prospective, observational study

BACKGROUND

High-flow nasal cannula (HFNC) oxygen is an alternative to conventional oxygen in acute hypoxaemic respiratory failure. Some patients require intubation, with a risk of delay; thus, early predictors may identify those requiring earlier intubation. The "ROX" index (ratio of pulse oximetry/fraction of inspired oxygen to respiratory rate) predicts intubation in patients with pneumonia treated with HFNC therapy, but this index has not been validated in non-pneumonia causes of acute hypoxaemic respiratory failure.

AIM/OBJECTIVE

The aim of this study was to identify factors associated with intubation in a heterogeneous group of patients with acute hypoxaemic respiratory failure treated with HFNC oxygen.

METHODS

This prospective observational study was undertaken in an Australian tertiary intensive care unit and included patients over 18 y of age with acute hypoxaemic respiratory failure who were treated with oxygen via HFNC. Vital signs and arterial blood gases were recorded prospectively at baseline and regular prespecified intervals for 48 h after HFNC initiation. Multivariate logistic regression was used to identify the factors associated with intubation.

RESULTS

Forty-three patients were included (N = 43). The multivariate factors associated with intubation were admission Sequential Organ Failure Assessment score (odds ratio [OR]: 1.94 [95% confidence interval {CI}: 1.06-3.57]; p = 0.032) and Pneumonia Severity Index (OR: 0.95 [95% CI: 0.90-0.99]; p = 0.034). The ROX index was not independently associated with intubation when adjusted for Sequential Organ Failure Assessment score (OR: 0.71 [95% CI: 0.47-1.06]; p = 0.09). There was no difference in mortality between patients intubated early (<24 h) compared to those intubated late.

CONCLUSIONS

Intubation was associated with admission Sequential Organ Failure Assessment score and Pneumonia Severity Index. The ROX index was not associated with intubation when adjusted for admission Sequential Organ Failure Assessment score. Outcomes were similar irrespective of whether patients were intubated late rather than early.

Effectiveness of bubble continuous positive airway pressure for treatment of children aged 1-59 months with severe pneumonia and hypoxaemia in Ethiopia: a pragmatic cluster-randomised controlled trial

BACKGROUND

The safety and efficacy of bubble continuous positive airway pressure (bCPAP) for treatment of childhood severe pneumonia outside tertiary care hospitals is uncertain. We did a cluster-randomised effectiveness trial of locally made bCPAP compared with WHO-recommended low-flow oxygen therapy in children with severe pneumonia and hypoxaemia in general hospitals in Ethiopia.

METHODS

This open, cluster-randomised trial was done in 12 general (secondary) hospitals in Ethiopia. We randomly assigned six hospitals to bCPAP as first-line respiratory support for children aged 1-59 months who presented with severe pneumonia and hypoxaemia and six hospitals to standard low-flow oxygen therapy. Cluster (hospital) randomisation was stratified by availability of mechanical ventilation. All children received treatment in paediatric wards (in a dedicated corner in front of a nursing station) with a similar level of facilities (equipment for oxygen therapy and medications) and staffing (overall, one nurse per six patients and one general practitioner per 18 patients) in all hospitals. All children received additional care according to WHO guidelines, supervised by paediatricians and general practitioners. The primary outcome was treatment failure (defined as any of the following: peripheral oxygen saturation <85% at any time after at least 1 h of intervention plus signs of respiratory distress; indication for mechanical ventilation; death during hospital stay or within 72 h of leaving hospital against medical advice; or leaving hospital against medical advice during intervention). The analysis included all children enrolled in the trial. We performed both unadjusted and adjusted analyses of the primary outcome, with the latter adjusted for the stratification variable and for the design effect of cluster randomisation, as well as selected potentially confounding variables, including age. We calculated effectiveness as the relative risk (RR) of the outcomes in the bCPAP group versus low-flow oxygen group. This trial is registered with ClinicalTrial.gov, NCT03870243, and is completed.

FINDINGS

From June 8, 2021, to July 27, 2022, 1240 children were enrolled (620 in hospitals allocated to bCPAP and 620 in hospitals allocated to low-flow oxygen). Cluster sizes ranged from 103 to 104 children. Five (0·8%) of 620 children in the bCPAP group had treatment failure compared with 21 (3·4%) of 620 children in the low-flow oxygen group (unadjusted RR 0·24, 95% CI 0·09-0·63, p=0·0015; adjusted RR 0·24, 0·07-0·87, p=0·030). Six children died during hospital stay, all of whom were in the low-flow oxygen group (p=0·031). No serious adverse events were attributable to bCPAP.

INTERPRETATION

In Ethiopian general hospitals, introduction of locally made bCPAP, supervised by general practitioners and paediatricians, was associated with reduced risk of treatment failure and in-hospital mortality in children with severe pneumonia and hypoxaemia compared with use of standard low-flow oxygen therapy. Implementation research is required in higher mortality settings to consolidate our findings.

FUNDING

SIDA Sweden and Grand Challenges Ethiopia.

Socio-demographic and comorbid risk factors for poor prognosis in patients hospitalized with community-acquired bacterial pneumonia in southeastern US

BACKGROUND

How socio-demographic characteristics and comorbidities affect bacterial community-acquired pneumonia (CAP) prognosis during/after hospitalization is important in disease management.

OBJECTIVES

To identify predictors of medical intensive care unit (MICU) admission, length of hospital stay (LOS), in-hospital mortality, and bacterial CAP readmission in patients hospitalized with bacterial CAP.

METHODS

ICD-9/10 codes were used to query electronic medical records to identify a cohort of patients hospitalized for bacterial CAP at a tertiary hospital in Southeastern US between 01/01/2013-12/31/2019. Adjusted accelerated failure time and modified Poisson regression models were used to examine predictors of MICU admission, LOS, in-hospital mortality, and 1-year readmission.

RESULTS

There were 1956 adults hospitalized with bacterial CAP. Median (interquartile range) LOS was 11 days (6-23), and there were 26 % (513) MICU admission, 14 % (266) in-hospital mortality, and 6 % (117) 1-year readmission with recurrent CAP. MICU admission was associated with heart failure (RR 1.38; 95 % CI 1.17-1.62) and obesity (RR 1.26; 95 % CI 1.04-1.52). Longer LOS was associated with heart failure (adjusted time ratio[TR] 1.27;95 %CI 1.12-1.43), stroke (TR 1.90;95 %CI 1.54,2.35), type 2 diabetes (TR 1.20;95 %CI 1.07-1.36), obesity (TR 1.50;95 %CI 1.31-1.72), Black race (TR 1.17;95 %CI 1.04-1.31), and males (TR 1.24;95 %CI 1.10-1.39). In-hospital mortality was associated with stroke (RR 1.45;95 %CI 1.03-2.04) and age ≥65 years (RR 1.34;95 %CI 1.06-1.68). 1-year readmission was associated with COPD (RR 1.55;95 %CI 1.05-2.27) and underweight BMI (RR 1.74;95 %CI 1.04-2.90).

CONCLUSIONS

Comorbidities and socio-demographic characteristics have varying impacts on bacterial CAP in-hospital prognosis and readmission. More studies are warranted to confirm these findings to develop comprehensive care plans and inform public health interventions.

Comparison of outcomes and characteristics of patients admitted to the ICU with COVID-19 and other community-acquired pneumonia based on propensity score matching

OBJECTIVE

To compare the similarities and differences between patients with Coronavirus Disease 2019 (COVID-19) and those with other community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU), utilizing propensity score matching (PSM), regarding hospitalization expenses, treatment options, and prognostic outcomes, aiming to inform the diagnosis and treatment of COVID-19.

METHODS

Patients admitted to the ICU of the Third People's Hospital of Datong City, diagnosed with COVID-19 from December 2022 to February 2023, constituted the observation group, while those with other CAP admitted from January to November 2022 formed the control group. Basic information, clinical data at admission, and time from symptom onset to admission were matched using PSM.

RESULTS

A total of 70 patients were included in the COVID-19 group and 119 in the CAP group. The patients were matched by the propensity matching method, and 37 patients were included in each of the last two groups. After matching, COVID-19 had a higher failure rate than CAP, but the difference was not statistically significant (73% vs. 51%, p = 0.055). The utilization rate of antiviral drugs (40% vs. 11%, p = 0.003), γ-globulin (19% vs. 0%, p = 0.011) and prone position ventilation (PPV) (27% vs. 0%, p < 0.001) in patients with COVID-19 were higher than those in the CAP, and the differences were statistically significant. The total hospitalization cost of COVID-19 patients was lower than that of CAP patients, and the difference was statistically significant (27889.5 vs. 50175.9, p = 0.007). The hospital stay for COVID-19 patients was shorter than for CAP patients, but the difference was not statistically significant (10.9 vs. 16.6, p = 0.071).

CONCLUSION

Our findings suggest that limited medical resources influenced patient outcomes during the COVID-19 pandemic. Addressing substantial demands for ICU capacity and medications during this period could have potentially reduced the mortality rate among COVID-19 patients.

Mesenchymal Stem Cell-Derived Exosomes Attenuate Murine Cytomegalovirus-Infected Pneumonia via NF-κB/NLRP3 Signaling Pathway

Reactivation and infection with cytomegalovirus (CMV) are frequently observed in recipients of solid organ transplants, bone marrow transplants, and individuals with HIV infection. This presents an increasing risk of allograft rejection, opportunistic infection, graft failure, and patient mortality. Among immunocompromised hosts, interstitial pneumonia is the most critical clinical manifestation of CMV infection. Recent studies have demonstrated the potential therapeutic benefits of exosomes derived from mesenchymal stem cells (MSC-exos) in preclinical models of acute lung injury, including pneumonia, ARDS, and sepsis. However, the role of MSC-exos in the pathogenesis of infectious viral diseases, such as CMV pneumonia, remains unclear. In a mouse model of murine CMV-induced pneumonia, we observed that intravenous administration of mouse MSC (mMSC)-exos reduced lung damage, decreased the hyperinflammatory response, and shifted macrophage polarization from the M1 to the M2 phenotype. Treatment with mMSC-exos also significantly reduced the infiltration of inflammatory cells and pulmonary fibrosis. Furthermore, in vitro studies revealed that mMSC-exos reversed the hyperinflammatory phenotype of bone marrow-derived macrophages infected with murine CMV. Mechanistically, mMSC-exos treatment decreased activation of the NF-κB/NLRP3 signaling pathway both in vivo and in vitro. In summary, our findings indicate that mMSC-exo treatment is effective in severe CMV pneumonia by reducing lung inflammation and fibrosis through the NF-κB/NLRP3 signaling pathway, thus providing promising therapeutic potential for clinical CMV infection.

Prevalence and factors associated with admission to the intensive care unit in children hospitalized for community-acquired pneumonia

OBJECTIVE.

To determine the prevalence and factors associated with intensive care unit admission in children and adolescents with community-acquired pneumonia.

MATERIALS AND METHODS.

Analytical cross-sectional observational study at the Instituto Nacional de Salud del Niño San Borja in 2019. The sample consisted of children older than one month and younger than 18 years who were admitted to emergency diagnosed with community-acquired pneumonia. We used Poisson regression to assess association.

RESULTS.

We evaluated 166 patients diagnosed with pneumonia, 94 (56.6%) were male and the median age was 24 months (IQR: 11 - 48). Most patients had a mild modified PIRO score of 136 (81.9%); 31 (18.7%) patients had complicated pneumonia and 24 (14.5%) were admitted to intensive care. The higher the age, the lower the prevalence of admission to ICU (PR=0.99, 95%CI: 0.98-0.99). The severity assessed with the modified PIRO score (PR=3.40, 95%CI: 1.46-7.93) and the presence of complicated pneumonia (PR: 5.88, 95%CI: 2.46-14.06) were associated with admission to intensive care.

CONCLUSIONS.

The prevalence of admission to intensive care in children with community-acquired pneumonia was 14.5%. Younger patients with pneumonia, with greater severity assessed with the modified PIRO score and with complicated pneumonia have a higher prevalence of admission to intensive care.

Community-acquired bacterial pneumonia in children: an update on antibiotic duration and immunization strategies

PURPOSE OF REVIEW

This review is structured to update clinicians on the epidemiology, antibiotic treatment, and prevention of pediatric bacterial pneumonia. The review provides information regarding the current research on antibiotic management for bacterial pneumonia and the newest immunization recommendations to prevent pneumococcal pneumonia and other respiratory infections.

RECENT FINDINGS

The recommended length of antibiotic therapy for bacterial pneumonia has been discrepant between low-income and high-income countries. Recently, randomized controlled trials conducted in high-income countries provided evidence to support a short antibiotic course (3-5 days) for uncomplicated bacterial pneumonia in otherwise healthy children. The negative impact of inaccurate penicillin allergy labels in children with pneumonia has emphasized the importance of prompt allergy de-labeling. Newer pneumococcal vaccines are recommended for children and are expected to have a significant impact on bacterial pneumonia rates.

SUMMARY

Pediatric bacterial pneumonia is an important contributor to childhood morbidity and mortality. A short antibiotic course seems to be sufficient for the outpatient management of uncomplicated bacterial pneumonia; however, more studies are required in the inpatient setting. Future studies will inform the impact of recently introduced pneumococcal and respiratory syncytial virus vaccines on the epidemiology of bacterial pneumonia.

Utilizing extracorporeal membrane oxygenation and surfactant in the management of severe acute respiratory distress syndrome due to hydrocarbon pneumonitis

Severe cases of hydrocarbon aspiration requiring Extracorporeal Membrane Oxygenation (ECMO) are rarely reported in pediatrics, and 90% of hospitalized patients have a relatively benign clinical course. We describe a 14 month-old female with accidental hydrocarbon ingestion and aspiration due to organic makeup brush cleaner that suffered severe ARDS and multiorgan failure, successfully managed with ECMO and surfactant. She was decannulated after a total of 72 hours on ECMO, extubated on hospital day 15 (HD 15), and discharged home in her normal state of health after one month in the hospital. ECMO and adjunctive therapies such as surfactant may be helpful in the management of severe hydrocarbon pneumonitis and there are limited reports of ECMO as a supportive method for these pediatric patients.

Challenges for a broad international implementation of the current severe community-acquired pneumonia guidelines

Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.

Predictors of recovery time from severe community-acquired pneumonia among paediatrics patients in selected hospitals in Addis Ababa, Ethiopia: an institution-based retrospective cohort study

OBJECTIVE

Severe community-acquired pneumonia (SCAP) is a significant cause of morbidity worldwide and a major cause of morbidity and mortality in developing countries. Ethiopia ranks 6th out of 15 countries with the highest mortality rate due to pneumonia in children under 5 years of age. The aim of this study was to determine the recovery time from SCAP and factors in paediatric patients in selected hospitals in Addis Ababa.

DESIGN, PARTICIPANTS AND SETTING

A retrospective cohort study was conducted among 407 randomly selected paediatric patients admitted with SCAP in Addis Ababa public hospitals from 1 January 2018 to 31 December 2020.

PRIMARY AND SECONDARY OUTCOMES

Recovery time and recovery rate from SCAP were estimated using Kaplan-Meier and simple frequency statistics, respectively, and the adjusted HR with a 95% CI was used to identify associated factors for recovery.

RESULTS

91.5% (95% CI: 88.3% to 94.1%) of children recovered from SCAP with an overall recovery rate of 11.5 (95% CI: 10.37 to 12.76) per 100 person-day observation, and the median recovery time was 6 days. In the multivariable analysis, older age and the absence of comorbidities were protective factors for early recovery, while stunting and late utilisation of medical care were risk factors.

CONCLUSION

The median recovery time after SCAP was very long compared with the optimal recovery time of 3 days given in the British Thoracic Society guidelines. Older age and absence of comorbidities were found to shorten recovery time, whereas stunting and late initiation of treatment delayed recovery. Therefore, measures that increase the recovery rate and shorten the recovery time, such as primary prevention to eliminate malnutrition and increase the utilisation of medical care in the community, should be strengthened, and health workers should focus on the early detection and treatment of comorbid diseases.

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study

OBJECTIVES

This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings.

DESIGN AND SETTING

We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries.

PARTICIPANTS

A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study.

PRIMARY OUTCOME MEASURES

We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations.

RESULTS

Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted.

CONCLUSIONS

Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

Clinicians Who Practice Primarily in Nursing Homes and the Quality of End-of-Life Care Among Residents

Importance

Clinician specialization in the care of nursing home (NH) residents or patients in skilled nursing facilities (SNFs) has become increasingly common. It is not known whether clinicians focused on NH care, often referred to as SNFists (ie, physicians, nurse practitioners, and physician assistants concentrating their practice in the NH or SNF setting), are associated with a reduced likelihood of burdensome transitions in the last 90 days of life for residents, which are a marker of poor-quality end-of-life (EOL) care.

Objective

To quantify the association between receipt of care from an SNFist and quality of EOL care for NH residents.

Design, Setting, and Participants

This cohort study analyzed Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries to examine burdensome transitions among NH decedents at the EOL from January 1, 2013, through December 31, 2019. Statistical analyses were conducted from December 2022 to June 2023.

Exposure

Receipt of care from an SNFist, defined as physicians and advanced practitioners who provided 80% or more of their evaluation and management visits in NHs annually.

Main Outcomes and Measures

This study used augmented inverse probability weighting in analyses of Medicare fee-for-service claims for a nationally representative 20% sample of beneficiaries. Main outcomes included 4 measures of burdensome transitions: (1) hospital transfer in the last 3 days of life; (2) lack of continuity in NHs after hospitalization in the last 90 days of life; (3) multiple hospitalizations in the last 90 days of life for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis; and (4) any hospitalization in the last 90 days of life for an ambulatory care-sensitive condition.

Results

Of the 2 091 954 NH decedents studied (mean [SD] age, 85.4 [8.5] years; 1 470 724 women [70.3%]), 953 722 (45.6%) received care from SNFists and 1 138 232 (54.4%) received care from non-SNFists; 422 575 of all decedents (20.2%) experienced a burdensome transition at the EOL. Receipt of care by an SNFist was associated with a reduced risk of (1) hospital transfer in the last 3 days of life (-1.6% [95% CI, -2.5% to -0.8%]), (2) lack of continuity in NHs after hospitalization (-4.8% [95% CI, -6.7% to -3.0%]), and (3) decedents experiencing multiple hospitalizations for any reason or any hospitalization for pneumonia, urinary tract infection, dehydration, or sepsis (-5.8% [95% CI, -10.1% to -1.7%]). There was not a statistically significant association with the risk of hospitalization for an ambulatory care-sensitive condition in the last 90 days of life (0.0% [95% CI, -14.7% to 131.7%]).

Conclusions and Relevance

This study suggests that SNFists may be an important resource to improve the quality of EOL care for NH residents.

Patient Engagement Functionalities' Influence on Quality Outcomes: The Road via EHR Presence

GOAL

Patients engaged in self-care through information technology can potentially improve the quality of healthcare they receive. This study aimed to examine how electronic health record (EHR) system functionalities help hospitals mediate the impact of patient engagement on quality outcomes-notably, readmission rates.

METHODS

A pooled cross-sectional study design employed data containing 3,547 observations from general acute care hospitals (2014-2018). The breadth of patient engagement functionalities adopted by a hospital was used as the independent variable and the degree of EHR presence was used as the mediating variable. Mean time to readmission for acute myocardial infarction (AMI), pneumonia, and heart failure were the dependent variables. The Baron and Kenny method was used to test mediation.

PRINCIPAL FINDINGS

Patient engagement was associated with reduced AMI readmission rates both directly and via EHR system presence. Mediation effects were present, in that a 1-unit increase in patient engagement through EHR system presence was associated with a 0.33% decrease in AMI readmission rates (p < .05). For other disease categories (heart failure and pneumonia), a significant effect was not found.

PRACTICAL APPLICATIONS

For hospitals with a comprehensive EHR system, patient engagement through information technology can potentially reduce readmission rates for some diseases. More research is needed to determine which specific clinical conditions are amenable to quality improvement through patient engagement. Synergies between patient engagement functionalities and an EHR system positively affect quality outcomes. Therefore, practitioners and hospital managers should leverage hospital investments made in their EHR system infrastructure and use it to engage patients in self-care.

ICU Utilization After Implementation of Minor Severe Pneumonia Criteria in Real-Time Electronic Clinical Decision Support

OBJECTIVES

To determine if the implementation of automated clinical decision support (CDS) with embedded minor severe community-acquired pneumonia (sCAP) criteria was associated with improved ICU utilization among emergency department (ED) patients with pneumonia who did not require vasopressors or positive pressure ventilation at admission.

DESIGN

Planned secondary analysis of a stepped-wedge, cluster-controlled CDS implementation trial.

SETTING

Sixteen hospitals in six geographic clusters from Intermountain Health; a large, integrated, nonprofit health system in Utah and Idaho.

PATIENTS

Adults admitted to the hospital from the ED with pneumonia identified by: 1) discharge International Classification of Diseases , 10th Revision codes for pneumonia or sepsis/respiratory failure and 2) ED chest imaging consistent with pneumonia, who did not require vasopressors or positive pressure ventilation at admission.

INTERVENTIONS

After implementation, patients were exposed to automated, open-loop, comprehensive CDS that aided disposition decision (ward vs. ICU), based on objective severity scores (sCAP).

MEASUREMENTS AND MAIN RESULTS

The analysis included 2747 patients, 1814 before and 933 after implementation. The median age was 71, median Elixhauser index was 17, 48% were female, and 95% were Caucasian. A mixed-effects regression model with cluster as the random effect estimated that implementation of CDS utilizing sCAP increased 30-day ICU-free days by 1.04 days (95% CI, 0.48-1.59; p < 0.001). Among secondary outcomes, the odds of being admitted to the ward, transferring to the ICU within 72 hours, and receiving a critical therapy decreased by 57% (odds ratio [OR], 0.43; 95% CI, 0.26-0.68; p < 0.001) post-implementation; mortality within 72 hours of admission was unchanged (OR, 1.08; 95% CI, 0.56-2.01; p = 0.82) while 30-day all-cause mortality was lower post-implementation (OR, 0.71; 95% CI, 0.52-0.96; p = 0.03).

CONCLUSIONS

Implementation of electronic CDS using minor sCAP criteria to guide disposition of patients with pneumonia from the ED was associated with safe reduction in ICU utilization.

Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia

OBJECTIVES

Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia.

METHODS

This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation.

RESULTS

Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%).

CONCLUSIONS

Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Severe pneumonia in patients with systemic lupus erythematosus admitted to the intensive care unit

BACKGROUND

The aim of this study was to investigate clinical characters and prognosis of patients with systemic lupus erythematosus (SLE) and severe pneumonia admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

We conducted a retrospective study that reviewed all clinical records of patients with SLE and severe pneumonia admitted to the ICU between 2008 and 2020.

RESULTS

A total of 86 SLE patients with severe pneumonia during their first ICU admission were enrolled in this study. Most patients were female (n = 71, 82.5%), and the median age was 42.3 ± 14.7 years. The most common organisms were gram-positive bacteria (20.9%), followed by gram-negative bacteria (18.6%) and fungi (10.4%). A total of 31 patients died within 30 days of ICU admission, and the 30-day mortality was 36%. In binary logistic regression analysis, Acute Physiologic and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score and mechanical ventilation were dependently associated with 30-day mortality (odds ratio [OR] 2.97, P = 0.016; OR = 4.02, P = 0.023; OR = 1.52, P = 0.036; respectively). Among the other 55 patients, 5 patients died after discharge from the ICU during the long-term follow-up.

CONCLUSIONS

Mortality was high in SLE patients with severe pneumonia admitted to the ICU, and most of the patients died within 30 days of ICU admission.

Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

OBJECTIVE

To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

DATA SOURCES AND STUDY SETTING

Secondary data from Medicare were used.

STUDY DESIGN

Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

CONCLUSIONS

HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

A large-scale production of mesenchymal stem cells and their exosomes for an efficient treatment against lung inflammation

Mesenchymal stem cells (MSCs) and their produced exosomes have demonstrated inherent capabilities of inflammation-guided targeting and inflammatory modulation, inspiring their potential applications as biologic agents for inflammatory treatments. However, the clinical applications of stem cell therapies are currently restricted by several challenges, and one of them is the mass production of stem cells to satisfy the therapeutic demands in the clinical bench. Herein, a production of human amnion-derived MSCs (hMSCs) at a scale of over 1 × 109 cells per batch was reported using a three-dimensional (3D) culture technology based on microcarriers coupled with a spinner bioreactor system. The present study revealed that this large-scale production technology improved the inflammation-guided migration and the inflammatory suppression of hMSCs, without altering their major properties as stem cells. Moreover, these large-scale produced hMSCs showed an efficient treatment against the lipopolysaccharide (LPS)-induced lung inflammation in mice models. Notably, exosomes collected from these large-scale produced hMSCs were observed to inherit the efficient inflammatory suppression capability of hMSCs. The present study showed that 3D culture technology using microcarriers coupled with a spinner bioreactor system can be a promising strategy for the large-scale expansion of hMSCs with improved anti-inflammation capability, as well as their secreted exosomes.

Weekend admissions and outcomes in patients with pneumonia: a systematic review and meta-analysis

Background

To document pooled evidence on the association between weekend hospital admissions and the potential risks of mortality, intensive care requirements, and readmission among patients with pneumonia.

Methods

We performed a systematic search across the PubMed, EMBASE, and Scopus databases. We collected observational studies exploring the association between weekend admissions and outcomes of interest in patients with pneumonia. To analyze the data, we used a random effects model and expressed the effect sizes as pooled odds ratios (ORs) accompanied by their respective 95% confidence intervals (CIs).

Results

The analysis comprised data from 13 retrospective studies. Compared to patients admitted on weekdays, those admitted during the weekend had a non-statistically significant marginally higher risk of in-hospital mortality (OR, 1.02; 95% CI, 1.00, 1.04) but similar 30-day mortality after admission (OR, 1.03; 95% CI, 0.97, 1.10), and similar risks of admission to intensive care unit (OR, 1.04; 95% CI, 0.98, 1.11) and re-admission (OR, 0.85; 95% CI, 0.65-1.12).

Conclusion

Our findings do not support the presence of a "weekend effect" in patients with pneumonia.

Systematic review registration

PROSPERO, identifier CRD42023425802, https://www.crd.york.ac.uk/prospero/.

Assessment of pre-referral treatment for malaria, diarrhea, and pneumonia by rural community health workers in Southwestern Uganda: a cross-sectional study

BACKGROUND

Pre-referral treatment aims to stabilize the child's condition before transferring them to a higher level of healthcare. This study explored pre-referral treatment for diarrhea, malaria and pneumonia in children U5. The study aims to assess pre-referral treatment practices among community health workers (CHWs) for children aged 2 to 59 months diagnosed with malaria, diarrhea, and pneumonia.

METHODS

Conducted in 2023, this study employed a quantitative retrospective analysis of secondary data gathered from March 2014 to December 2018. Among the subjects, 171 patients received pre-referral treatment, serving as the foundation for categorical data analysis, presenting proportions and 95% confidence intervals across different categories.

RESULTS

In this cohort, 90 (53%) of the 177 children U5 were male, and age distribution showed 39 (23%), 70 (41%), and 62 (36%) in the 2-11 months, 12-35 months, and 36-60 months categories, respectively. Rapid Diagnostic Test (RDT) malaria results indicated a negative outcome in 83(60%) and positive in 55 (40%) of cases. Symptomatically, 45 (26%) had diarrhea, 52 (30%) exhibited fast breathing, and 109 (63%) presented with fever. Furthermore, 59 (35%) displayed danger signs, while 104 (61%) sought medical attention within 24 h.

CONCLUSION

The study analyzed a sample of 171 children under 5 years old to assess various characteristics and variables related to pre-referral treatment. The findings reveal notable proportions in gender distribution, age categories, RDT results, presence of diarrhea, fast breathing, fever, danger signs, and timely medical visits. The results highlight the need to strengthen pre-referral treatment interventions and enhance iCCM programs.

The correlation between lung ultrasound scores and outcomes of high-flow nasal cannula therapy in infants with severe pneumonia

OBJECTIVE

The study aimed to explore the effectiveness of bedside lung ultrasound (LUS) combined with the PaO2/FiO2 (P/F) ratio in evaluating the outcomes of high-flow nasal cannula (HFNC) therapy in infants with severe pneumonia.

METHODS

This retrospective study analyzed the clinical data of 150 infants diagnosed with severe pneumonia and treated with HFNC therapy at our hospital from January 2021 to December 2021. These patients were divided into two groups based on their treatment outcomes: the HFNC success group (n = 112) and the HFNC failure group (n = 38). LUS was utilized to evaluate the patients' lung conditions, and blood gas results were recorded for both groups upon admission and after 12 h of HFNC therapy.

RESULTS

At admission, no significant differences were observed between the two groups in terms of age, gender, respiratory rate, partial pressure of oxygen, and partial pressure of carbon dioxide. However, the P/F ratios at admission and after 12 h of HFNC therapy were significantly lower in the HFNC failure group (193.08 ± 49.14, 228.63 ± 80.17, respectively) compared to the HFNC success group (248.51 ± 64.44, 288.93 ± 57.17, respectively) (p < 0.05). Likewise, LUS scores at admission and after 12 h were significantly higher in the failure group (18.42 ± 5.3, 18.03 ± 5.36, respectively) than in the success group (15.09 ± 4.66, 10.71 ± 3.78, respectively) (p < 0.05). Notably, in the success group, both P/F ratios and LUS scores showed significant improvement after 12 h of HFNC therapy, a trend not observed in the failure group. Multivariate regression analysis indicated that lower P/F ratios and higher LUS scores at admission and after 12 h were predictive of a greater risk of HFNC failure. ROC analysis demonstrated that an LUS score > 20.5 at admission predicted HFNC therapy failure with an AUC of 0.695, a sensitivity of 44.7%, and a specificity of 91.1%. A LUS score > 15.5 after 12 h of HFNC therapy had an AUC of 0.874, with 65.8% sensitivity and 89.3% specificity. An admission P/F ratio < 225.5 predicted HFNC therapy failure with an AUC of 0.739, 60.7% sensitivity, and 71.1% specificity, while a P/F ratio < 256.5 after 12 h of HFNC therapy had an AUC of 0.811, 74.1% sensitivity, and 73.7% specificity.

CONCLUSION

Decreased LUS scores and increased P/F ratio demonstrate a strong correlation with successful HFNC treatment outcomes in infants with severe pneumonia. These findings may provide valuable support for clinicians in managing such cases.

Factors associated with an increased risk of developing pneumonia during acute ischemic stroke hospitalization

Stroke-associated pneumonia (SAP) is a common complication of acute ischemic stroke (AIS). This single-center retrospective observational study aimed to identify factors associated with SAP and predictors of poor outcomes in hospitalized patients with AIS. The study included patients admitted to Chumphon Khet Udomsakdi Hospital in Thailand within 7 days of the onset of AIS between July 2019 and July 2020. The patients were divided according to whether they were diagnosed with SAP during hospitalization into a pneumonia group and a non-pneumonia (control) group. Factors associated with SAP were identified. After 3 months, the patients with AIS were divided into those with a poor outcome (modified Rankin scale [mRS] score ≥4) and those with a non-poor outcome (mRS score <4). Factors associated with a poor outcome were sought. During the study period, 342 patients (mean age 65 years, 61% men) were admitted with AIS, of whom 54 (15.8%) developed SAP. Multivariate analysis identified a failed water-swallowing test (WST; adjusted odds ratio [aOR] 87.48, 95% confidence interval [CI] 21.00-364.51, p<0.001), endotracheal intubation with invasive mechanical ventilation (aOR 12.38, 95% CI 2.44-101.35, p = 0.001), and a retained Foley catheter (aOR 5.67, 95% CI 2.03-15.83, p = 0.001) to be associated with SAP. Of the 342 patients, 112 (32.7%) had a poor outcome at 3 months, predictors of which included having hypertension as a comorbidity (aOR 2.87, 95% CI 1.18-6.98, p = 0.020), a pre-stroke mRS score ≥2 (aOR 4.53, 95% CI 1.50-12.72, p = 0.007), an initial Barthel Index score <40 (aOR 3.35, 95% CI 1.57-7.16, p = 0.002), a failed WST (aOR 5.04, 95% CI 2.00-12.74, p = 0.001), and brain edema (aOR 20.67, 95% CI 2.10-203.26, p = 0.009). This study emphasized the association of SAP with a failed WST, endotracheal intubation with invasive mechanical ventilation, and a retained Foley catheter but also identified hypertension, a pre-stroke mRS score ≥2, an initial BI score <40, a failed WST, and brain edema as predictors of a poor outcome for patients 3 months after AIS.

Venous-arterial extracorporeal membrane oxygenation for psittacosis pneumonia complicated with cardiogenic shock: case report and literature review

INTRODUCTION

Dilated cardiomyopathy (DCM) is characterized by the enlargement of the left ventricle or biventricular, accompanied by myocardial systolic dysfunction. Chlamydia psittacosis (CP) is a zoonotic pathogen, which can cause severe pneumonia, respiratory failure, and acute organ dysfunction. The deterioration of DCM caused by CP infection is extremely rare, and few cases of successful management were reported.

CASE PRESENTATION

We reported a 67-year-old male patient with DCM and chronic heart failure. Who was admitted to ICU with severe pneumonia, acute hypoxemic respiratory failure, acute decompensated heart failure, arrhythmia, and cardiogenic shock. Mechanical ventilation (MV) and venous-arterial extracorporeal membrane oxygenation (VA-ECMO) were established for respiratory and circulatory support. Broncho alveolar lavage fluid(BALF)was collected for culture and metagenomics next-generation sequencing (mNGS) test. Repeated mNGS tests indicated the high possibility of CP pneumonia, thereafter, moxifloxacin and doxycycline were prescribed. After targeted antibiotics and organ support treatment, pneumonia, respiratory and circulatory failure were gradually resolved, patient was successfully weaned from MV and VA-ECMO. Finally, the patient was recovered and discharged alive.

CONCLUSIONS

Severe respiratory and circulatory failure caused by CP infection in DCM patients is a rare life-threatening clinical condition. Early accurate diagnosis, targeted antibiotic therapy, coupled with extracorporeal life support posed positive impact on the patient's disease course and outcome.

Assessment of quality of care for hospitalized non-COVID-19 older adult patients with pneumonia before and after the COVID-19 pandemic

BACKGROUND

There is limited research into the clinical implications of the coronavirus disease 2019 (COVID-19) pandemic for non-COVID-19 pneumonia in older adults, as well as their quality of care or outcomes. This study aims to assess the process and outcome quality of care for hospitalized older adult patients with pneumonia before and after the pandemic.

METHODS

A retrospective cohort of older adult patients (age ≥ 65) hospitalized for non-COVID pneumonia were recruited from five Korean hospitals (January 20, 2019, to January 19, 2021). The quality of care before and after the COVID-19 pandemic was evaluated.

RESULTS

A total of 7356 hospitalization episodes of older adult pneumonia were identified, and 978 cases (552 pre-pandemic and 426 during the pandemic) were analyzed. The pneumonia severity score was higher during the pandemic, and the waiting time from the emergency room to admission was also longer. Furthermore, the pneumonia mortality rate during the pandemic was higher than that in the pre-pandemic period (in-hospital mortality: 10.1% vs. 18.1%; 90-day mortality: 11.6% vs. 22.3%). A significantly higher mortality risk was observed during the pandemic than in the period prior (adjusted odds ratio: 1.74, 95% confidence interval: 1.14-2.63).

CONCLUSIONS

While the quality of care for hospitalized pneumonia has been maintained during the pandemic, there has been an increase in mortality rates. Further investigations are needed to understand the underlying causes of this increase.

Non-Invasive Ventilation for Community-Acquired Pneumonia: Outcomes and Predictors of Failure from an ICU Cohort

Background and Objectives: The use of non-invasive ventilation (NIV) for community-acquired pneumonia (CAP) remains controversial. NIV failure in the setting of acute hypoxemic respiratory failure is associated with increased mortality, highlighting the need for careful patient selection. Methods and Methods: This is a retrospective observational cohort study. We included 140 patients with severe CAP, treated with either NIV or invasive mechanical ventilation (IMV) as their primary oxygenation strategy. Results: The median PaO2/FiO2 ratio and SOFA score upon ICU admission were 151 mmHg and 6, respectively. We managed 76% of patients with NIV initially and report an NIV success rate of 59%. Overall, the 28-day mortality was 25%, whilst for patients with NIV success, the mortality was significantly lower at 13%. In the univariate analysis, NIV failure was associated with the SOFA score (OR 1.33), the HACOR score (OR 1.14) and the presence of septic shock (OR 3.99). The SOFA score has an AUC of 0.75 for NIV failure upon ICU admission, whilst HACOR has an AUC of 0.76 after 2 h of NIV. Conclusions: Our results suggest that a SOFA ≤ 4 and an HACOR ≤ 5 are reasonable thresholds to identify patients with severe CAP likely to benefit from NIV.

[Application of metagenomic next-generation sequencing of bronchoalveolar lavage fluid in the diagnosis and treatment of refractory pneumonia in children]

OBJECTIVES

To investigate the clinical application of metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) in the etiological diagnosis and treatment of refractory pneumonia (RTP) in children.

METHODS

A retrospective analysis was performed on 160 children with RTP who were admitted to the Department of Pediatric Internal Medicine, Maternal and Child Health Hospital of Inner Mongolia Autonomous Region, from January 2020 to March 2023. According to whether mNGS was performed, they were divided into two groups: mNGS (n=80) and traditional testing (n=80). All children received the tests of inflammatory markers and pathogen tests after admission. Traditional pathogenicity tests included microbial culture (sputum specimen collected by suction tube), nucleic acid detection of respiratory pathogens, and serological test (mycoplasma, tuberculosis, and fungi). For the mNGS group, BALF specimens were collected after bronchoscopy and were sent to the laboratory for mNGS and microbial culture. The two groups were analyzed and compared in terms of the detection of pathogens and treatment.

RESULTS

Compared with the traditional testing group, the mNGS group had a significantly higher detection rate of pathogens (92% vs 58%, P<0.05), with more types of pathogens and a higher diagnostic rate of mixed infections. Compared with the traditional testing group, the mNGS group had a significantly higher treatment response rate and a significantly lower incidence rate of complications during hospitalization (P<0.05). Treatment was adjusted for 68 children in the mNGS group according to the results of mNGS, with a treatment response rate of 96% (65/68) after adjustment.

CONCLUSIONS

Compared with traditional pathogen tests, BALF mNGS can significantly improve the detection rate of pathogens and find some rare pathogens. In clinical practice, when encountering bottlenecks during the diagnosis and treatment of children with RTP, it is advisable to promptly perform the mNGS to identify the pathogens.

Community-acquired pneumonia: Epidemiology, diagnosis, prognostic severity scales, and new therapeutic options

This narrative review article explores the current scientific knowledge on the definition, epidemiology, diagnostic criteria, microbiology, treatment, and prevention of severe community-acquired pneumonia (SCAP) in immunocompetent adults. At present, despite major scientific advances in diagnostic evaluation, clinical management, antimicrobial therapy, and prevention, severe community-acquired pneumonia remains a major cause of morbidity and mortality, as well as having a major economic impact in terms of increased healthcare expenditure worldwide. This pathology is considered one of the leading causes of sepsis/septic shock, with an extremely high overall mortality rate, which justifies all the effort in early diagnosis, proper management, and prompt initiation of antimicrobial therapy. Including biomarkers (isolated or in combination) associated with applying diagnostic criteria and prognostic severity scales in clinical practice helps identify patients with severe community-acquired pneumonia, defines immediate admission to the intensive care unit, and, thus, minimizes the adverse outcomes of this serious pathology.

Outcomes of Veterans Treated in Veterans Affairs Hospitals vs Non-Veterans Affairs Hospitals

Importance

Many veterans enrolled in the Veterans Affairs (VA) health care system have access to non-VA care through insurance and VA-purchased community care. Prior comparisons of VA and non-VA hospital outcomes have been limited to subpopulations.

Objective

To compare outcomes for 6 acute conditions in VA and non-VA hospitals for younger and older veterans using VA and all-payer discharge data.

Design, Setting, and Participants

This cohort study used a repeated cross-sectional analysis of hospitalization records for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), gastrointestinal (GI) hemorrhage, heart failure (HF), pneumonia, and stroke. Participants included VA enrollees from 11 states at VA and non-VA hospitals from 2012 to 2017. Analysis was conducted from July 1, 2022, to October 18, 2023.

Exposures

Treatment in VA or non-VA hospital.

Main Outcome and Measures

Thirty-day mortality, 30-day readmission, length of stay (LOS), and costs. Average treatment outcomes of VA hospitals were estimated using inverse probability weighted regression adjustment to account for selection into hospitals. Models were stratified by veterans' age (aged less than 65 years and aged 65 years and older).

Results

There was a total of 593 578 hospitalizations and 414 861 patients with mean (SD) age 75 (12) years, 405 602 males (98%), 442 297 hospitalizations of non-Hispanic White individuals (75%) and 73 155 hospitalizations of non-Hispanic Black individuals (12%) overall. VA hospitalizations had a lower probability of 30-day mortality for HF (age ≥65 years, -0.02 [95% CI, -0.03 to -0.01]) and stroke (age <65 years, -0.03 [95% CI, -0.05 to -0.02]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.03]). VA hospitalizations had a lower probability of 30-day readmission for CABG (age <65 years, -0.04 [95% CI, -0.06 to -0.01]; age ≥65 years, -0.05 [95% CI, -0.07 to -0.02]), GI hemorrhage (age <65 years, -0.04 [95% CI, -0.06 to -0.03]), HF (age <65 years, -0.05 [95% CI, -0.07 to -0.03]), pneumonia (age <65 years, -0.04 [95% CI, -0.06 to -0.03]; age ≥65 years, -0.03 [95% CI, -0.04 to -0.02]), and stroke (age <65 years, -0.11 [95% CI, -0.13 to -0.09]; age ≥65 years, -0.13 [95% CI, -0.16 to -0.10]) but higher probability of readmission for AMI (age <65 years, 0.04 [95% CI, 0.01 to 0.06]). VA hospitalizations had a longer mean LOS and higher costs for all conditions, except AMI and stroke in younger patients.

Conclusions and Relevance

In this cohort study of veterans, VA hospitalizations had lower mortality for HF and stroke and lower readmissions, longer LOS, and higher costs for most conditions compared with non-VA hospitalizations with differences by condition and age group. There were tradeoffs between better outcomes and higher resource use in VA hospitals for some conditions.

Readmission following hospital admission for community-acquired pneumonia in England

INTRODUCTION

Readmission rates following hospital admission with community-acquired pneumonia (CAP) have increased in the UK over the past decade. The aim of this work was to describe the cohort of patients with emergency 30-day readmission following hospitalisation for CAP in England and explore the reasons for this.

METHODS

A retrospective analysis of cases from the British Thoracic Society national adult CAP audit admitted to hospitals in England with CAP between 1 December 2018 and 31 January 2019 was performed. Cases were linked with corresponding patient level data from Hospital Episode statistics, providing data on the primary diagnosis treated during readmission and mortality. Analyses were performed describing the cohort of patients readmitted within 30 days, reasons for readmission and comparing those readmitted and primarily treated for pneumonia with other diagnoses.

RESULTS

Of 8136 cases who survived an index admission with CAP, 1304 (15.7%) were readmitted as an emergency within 30 days of discharge. The main problems treated on readmission were pneumonia in 516 (39.6%) patients and other respiratory disorders in 284 (21.8%). Readmission with pneumonia compared with all other diagnoses was associated with significant inpatient mortality (15.9% vs 6.5%; aOR 2.76, 95% CI 1.86 to 4.09, p<0.001). A diagnosis of hospital-acquired infection was more frequent in readmissions treated for pneumonia than other diagnoses (22.1% vs 3.9%, p<0.001).

CONCLUSION

Pneumonia is the most common condition treated on readmission following hospitalisation with CAP and carries a higher mortality than both the index admission or readmission due to other diagnoses. Strategies to reduce readmissions due to pneumonia are required.

Clinical trials of pneumonia management assess heterogeneous outcomes and measurement instruments

OBJECTIVES

To inform clinical practice guidelines, randomized controlled trials (RCTs) of the management of pneumonia need to address the outcomes that are most important to patients and health professionals using consistent instruments, to enable results to be compared, contrasted, and combined as appropriate. This systematic review describes the outcomes reported in clinical trials of pneumonia management and the instruments used to measure these outcomes.

STUDY DESIGN AND SETTING

Based on a prospective protocol, we searched MEDLINE/PubMed, Cochrane CENTRAL and clinical trial registries for ongoing or completed clinical trials evaluating pneumonia management in adults in any clinical setting. We grouped reported outcomes thematically and classified them following the COMET Initiative's taxonomy. We describe instruments used for assessing each outcome.

RESULTS

We found 280 eligible RCTs of which 115 (41.1%) enrolled critically ill patients and 165 (58.9%) predominantly noncritically ill patients. We identified 43 distinct outcomes and 108 measurement instruments, excluding nonvalidated scores and questionnaires. Almost all trials reported clinical/physiological outcomes (97.5%). Safety (63.2%), mortality (56.4%), resource use (48.6%) and life impact (11.8%) outcomes were less frequently addressed. The most frequently reported outcomes were treatment success (60.7%), mortality (56.4%) and adverse events (41.1%). There was significant variation in the selection of measurement instruments, with approximately two-thirds used in less than 10 of the 280 RCTs. None of the patient-reported outcomes were used in 10 or more RCTs.

CONCLUSION

This review reveals significant variation in outcomes and measurement instruments reported in clinical trials of pneumonia management. Outcomes that are important to patients and health professionals are often omitted. Our findings support the need for a rigorous core outcome set, such as that being developed by the European Respiratory Society.

Investigating the Effects of Intervention Strategies on Pneumonia and HIV/AIDS Coinfection Model

HIV/AIDS and pneumonia coinfection have imposed a major socioeconomic and health burden throughout the world, especially in the developing countries. In this study, we propose a compartmental epidemic model on the spreading dynamics of HIV/AIDS and pneumonia coinfection to investigate the impacts of protection and treatment intervention mechanisms on the coinfection spreading in the community. In the qualitative analysis of the model, we have performed the positivity and boundedness of the coinfection model solutions; the effective reproduction numbers using the next-generation operator approach; and both the disease-free and endemic equilibrium points' local and global stabilities using the Routh-Hurwiz and Castillo-Chavez stability criteria, respectively. We performed the sensitivity analysis of the model parameters using both the forward normalized sensitivity index criteria and numerical methods (simulation). Moreover, we carried out the numerical simulation for different scenarios to investigate the effect of model parameters on the associated reproduction number, the effect of model parameters on the model state variables, and the solution behavior and convergence to the equilibrium point(s) of the models. Finally, from the qualitative analysis and numerical simulation results, we observed that the disease-spreading rates, protection rates, and treatment rates are the most sensitive parameters, and we recommend for stakeholders to concentrate and exert their maximum effort to minimize the spreading rates by maximizing the protection and treatment rates.

Evaluation of feasibility phase of adaptive version of locally made bubble continuous positive airway pressure oxygen therapy for the treatment of COVID-19 positive and negative adults with severe pneumonia and hypoxaemia

Background

Bubble continuous positive airway pressure (bCPAP) oxygen therapy has been shown to be safe and effective in treating children with severe pneumonia and hypoxaemia in Bangladesh. Due to lack of adequate non-invasive ventilatory support during coronavirus disease 2019 (COVID-19) crisis, we aimed to evaluate whether bCPAP was safe and feasible when adapted for use in adults with similar indications.

Methods

Adults (18-64 years) with severe pneumonia and moderate hypoxaemia (80 to <90% oxygen saturation (SpO2) in room air) were provided bCPAP via nasal cannula at a flow rate of 10 litres per minute (l/min) oxygen at 10 centimetres (cm) H2O pressure, in two tertiary hospitals in Dhaka, Bangladesh. Qualitative interviews and focus group discussions, using a descriptive phenomenological approach, were performed with patients and staff (n = 39) prior to and after the introduction (n = 12 and n = 27 respectively) to understand the operational challenges to the introduction of bCPAP.

Results

We enrolled 30 adults (median age 52, interquartile range (IQR) 40-60 years) with severe pneumonia and hypoxaemia and/or acute respiratory distress syndrome (ARDS) irrespective of coronavirus disease 2019 (COVID-19) test results to receive bCPAP. At baseline mean SpO2 on room air was 87% (±2) which increased to 98% (±2), after initiation of bCPAP. The mean duration of bCPAP oxygen therapy was 14.4 ± 24.8 hours. There were no adverse events of note, and no treatment failure or deaths. Operational challenges to the clinical introduction of bCPAP were lack of functioning pulse oximeters, difficult nasal interface fixation among those wearing nose pin, occasional auto bubbling or lack of bubbling in water-filled plastic bottle, lack of holder for water-filled plastic bottle, rapid turnover of trained clinicians at the hospitals, and limited routine care of patients by hospital clinicians particularly after official hours.

Discussion

If the tertiary hospitals in Bangladesh are supplied with well-functioning good quality pulse oximeters and enhanced training of the doctors and nurses on proper use of adapted version of bCPAP, in treating adults with severe pneumonia and hypoxaemia with or without ARDS, the bCPAP was found to be safe, well tolerated and not associated with treatment failure across all study participants. These observations increase the confidence level of the investigators to consider a future efficacy trial of adaptive bCPAP oxygen therapy compared to WHO standard low flow oxygen therapy in such patients.

Conclusion

s Although bCPAP oxygen therapy was found to be safe and feasible in this pilot study, several challenges were identified that need to be taken into account when planning a definitive clinical trial.

PD-L1-Expressing Extracellular Vesicles for the Treatment of Pneumonia

Acute respiratory distress syndrome (ARDS) is a severe lung condition with a high mortality rate and a lack of effective drug therapy. In this work, we developed mesenchymal stem cell (MSC)-derived extracellular vesicles with high PD-L1 expression (MSC-EVs-PD-L1) for treating lipopolysaccharide (LPS)-induced pneumonia by intratracheal administration. We found an upregulation of PD-1 expression in the inflammatory region of murine lungs; hence, MSC-EVs-PD-L1 exerted immunosuppressive effects via the PD-1/PD-L1 signaling pathway. Furthermore, we treated LPS-induced pneumonia mice by intratracheal administration, which enabled heavy drug accumulation in the lungs of mice and better therapeutic efficacy compared to systemic administration. Our results suggest that MSC-EVs-PD-L1 has the potential to provide a universal platform technology for the immunotherapy of pneumonia.

Clinical application of metagenomic next-generation sequencing in non-immunocompromised patients with severe pneumonia supported by veno-venous extracorporeal membrane oxygenation

Objectives

This study aims to explore the pathogen-detected effect of mNGS technology and its clinical application in non-immunocompromised patients with severe pneumonia supported by vv-ECMO.

Methods

A retrospective analysis was conducted on a cohort of 50 non-immunocompromised patients who received vv-ECMO support for severe pneumonia between January 2016 and December 2022. These patients were divided into two groups based on their discharge outcomes: the deterioration group (Group D), which included 31 cases, and the improvement group (Group I), consisting of 19 cases. Baseline characteristics and clinical data were collected and analyzed.

Results

Among the 50 patients enrolled, Group D exhibited a higher prevalence of male patients (80.6% vs. 52.6%, p < 0.05), more smokers (54.8% vs. 21.1%, p < 0.05), and were older than those in Group I (55.16 ± 16.34 years vs. 42.32 ± 19.65 years, p < 0.05). Out of the 64 samples subjected to mNGS detection, 55 (85.9%) yielded positive results, with a positivity rate of 83.7% (36/43) in Group D and 90.5% (19/21) in Group I. By contrast, the positive rate through traditional culture stood at 64.9% (74/114). Among the 54 samples that underwent both culture and mNGS testing, 23 (42.6%) displayed consistent pathogen identification, 13 (24.1%) exhibited partial consistency, and 18 (33.3%) showed complete inconsistency. Among the last cases with complete inconsistency, 14 (77.8%) were culture-negative, while two (11.1%) were mNGS-negative, and the remaining two (11.1%) presented mismatches. Remarkably, mNGS surpassed traditional culture in pathogen identification (65 strains vs. 23 strains). Within these 65 strains, 56 were found in Group D, 26 in Group I, and 17 were overlapping strains. Interestingly, a diverse array of G+ bacteria, fungi, viruses, and special pathogens were exclusive to Group D. Furthermore, Acinetobacter baumannii, Pseudomonas aeruginosa, and Klebsiella pneumoniae were more prevalent in Group D compared to Group I. Importantly, mNGS prompted antibiotic treatment adjustments in 26 patients (52.0%).

Conclusions

Compared with the conventional culture, mNGS demonstrated a higher positive rate, and emerges as a promising method for identifying mixed pathogens in non-immunodeficient patients with severe pneumonia supported by vv-ECMO. However, it is crucial to combine the interpretation of mNGS data with clinical information and traditional culture results for a comprehensive assessment.

Delay in healthcare seeking for young children with severe pneumonia at Mulago National Referral Hospital, Uganda: A mixed methods cross-sectional study

BACKGROUND

Globally, pneumonia is the leading infectious cause of under-five mortality, and this can be reduced by prompt healthcare seeking. Data on factors associated with delays in seeking care for children with pneumonia in Uganda is scarce.

OBJECTIVES

The study aimed to determine the prevalence, factors associated with delay, barriers, and facilitators of prompt healthcare seeking for children under five years of age with severe pneumonia attending Mulago National Referral Hospital (MNRH) Uganda.

METHODS

A mixed methods cross-sectional study was conducted among 384 caregivers of children with severe pneumonia at MNRH. Quantitative data was collected using interviewer-administered structured questionnaires and qualitative data through focus group discussions with caregivers. Descriptive statistics were used to determine the prevalence of delay in care seeking. Logistic regression analysis was used to determine the factors that were independently associated with delay in seeking healthcare. Content thematic analysis was used to analyze for barriers and facilitators of prompt healthcare seeking.

RESULTS

The prevalence of delay in seeking healthcare was 53.6% (95% CI: 48.6-58.6). Long distance to a hospital (AOR = 1.94, 95% CI 1.22-3.01, p value = 0.003), first seeking care elsewhere (AOR = 3.33, 95% CI 1.85-6.01, p value = 0.001), and monthly income ≤100,000 UGX (28 USD) (AOR = 2.27,95% CI 1.33-3.86, p value = 0.003) were independently associated with delay in seeking healthcare. Limited knowledge of symptoms, delayed referrals, self-medication, and low level of education were barriers to prompt healthcare seeking while recognition of symptoms of severe illness in the child, support from spouses, and availability of money for transport were key facilitators of early healthcare seeking.

CONCLUSION

This study showed that more than half of the caregivers delayed seeking healthcare for their children with pneumonia symptoms. Caregivers who first sought care elsewhere, lived more than 5 km from the hospital, and earned less than 28 USD per month were more likely to delay seeking healthcare for their children with severe pneumonia. Limited knowledge of symptoms of pneumonia, self-medication, and delayed referral hindered prompt care-seeking. Key facilitators of prompt care-seeking were accessibility to health workers, support from spouses, and recognition of symptoms of severe illness in children. There is a need for programs that educate caregivers about pneumonia symptoms, in children less than five years.

The prognostic value of rapid risk scores among patients with community-acquired pneumonia : A retrospective cohort study

BACKGROUND

Community-acquired pneumonia (CAP) is a frequent reason for emergency department (ED) presentations. Various risk scores have been validated in the management of CAP and are recommended for daily practice.

OBJECTIVE

The aim of the study was to evaluate the performance of the rapid risk scores (the rapid acute physiology score (RAPS), the rapid emergency medicine score (REMS), the Worthing physiological scoring system (WPS), CURB-65 and CRB-65) among patients with CAP.

METHODS

This retrospective cohort study was conducted in the ED of a tertiary hospital between 1 January 2019 and 31 December 2019. Patients aged ≥ 18 years and diagnosed with CAP were included. Patients who were transferred from another center or with missing records were excluded. Demographic information, vital signs, level of consciousness, laboratory results, and outcomes were recorded.

RESULTS

A total of 2057 patients were included in the final analysis. The 30-day mortality of the patients was 15.2% (n = 312). The WPS achieved the most successful results for all three outcomes, 30-day mortality, intensive care unit (ICU) admission and mechanical ventilation (MV) needs (area under the curve, AUC 0.810, 0.918, and 0.910, respectively; p < 0.001). In the prediction of mortality, RAPS, REMS, CURB-65, and CRB-65 had a moderate overall performance (AUC 0.648, 0.752, 0.778, and 0.739, respectively). In the prediction of ICU admission and MV needs, RAPS, REMS, CURB-65, and CRB-65 had moderate to good overall performance (AUC at ICU admission 0.793, 0.873, 0.829, and 0.810; AUC for MV needs 0.759, 0.892, 0.754, and 0.738, respectively). Advanced age, lower levels of mean arterial pressure and peripheral oxygen saturation, presence of active malignancy and cerebrovascular disease, and ICU admission were associated with mortality (p < 0.05).

CONCLUSION

The WPS outperformed other risk scores in patients with CAP and can be used safely. The CRB-65 can be used to discriminate critically ill patients with CAP due to its high specificity. The overall performances of the scores were satisfactory for all three outcomes.

Post-stroke pneumonia: Factors associated with readmission within 90 days of stroke discharge

OBJECTIVE

The objective was to identify risk and protective factors associated with post-stroke pneumonia readmission.

METHOD

A retrospective chart review was conducted on 365 stroke patients who were admitted to Ascension Via Christi St. Francis Hospital in Wichita, Kansas from January 1, 2015 through January 30, 2020. This case control study used matching by age at a proportion of four control patients to one post-stroke pneumonia patient. Patients with and without post-stroke pneumonia readmission within 90 days of discharge were included in this study.

RESULTS

Of the 3,952 patients diagnosed with stroke, 1.8% (n=73) patients were readmitted with post-stroke pneumonia. Compared to patients who were not readmitted for post-stroke pneumonia, patients with post-stroke pneumonia readmission were more likely to: have used a nasogastric tube during index admission, have used mechanical ventilation during index admission, or have been placed on a nothing-by-mouth diet at discharge. Being placed on nothing-by-mouth for fluids was also a predictor of post-stroke pneumonia readmission. Lack of acquired infection during the index admission was a protective factor for post-stroke pneumonia readmission.

DISCUSSION

The pathophysiology of post-stroke pneumonia is multifactorial and includes consideration of dysphagia severity, bacterial colonization of the oropharynx and feeding tube, and an altered immune system.

CONCLUSION

During the index admission, patients on nothing-by-mouth were more likely to be readmitted, and infection-free patients were less likely to be readmitted with post-stroke pneumonia. By identifying at-risk patients, clinicians may be able to use this information to tailor future medical interventions to prevent post-stroke pneumonia readmissions.

Proposed protocol for utilising high-flow nasal oxygen therapy in treatment of dogs hospitalised due to pneumonia

BACKGROUND

High-flow nasal oxygen (HFNO) therapy is a non-invasive respiratory support method that provides oxygen-enriched, warmed, and humidified air to respiratory-compromised patients. It is widely used in human medical care, but in veterinary medicine it is still a relatively new method. No practical guidelines exist for its use in canine pneumonia patients, although they could potentially benefit from HFNO therapy. This study aims to provide a new, safe, non-invasive, and effective treatment protocol for oxygen supplementation of non-sedated dogs with pneumonia.

METHODS

Twenty privately owned dogs with pneumonia will receive HFNO therapy at a flow rate of 1-2 L/kg, and the fraction of inspired oxygen will be determined individually (ranging from 21% to 100%). HFNO therapy will continue as long as oxygen support is needed based on clinical evaluation. Patients will be assessed thrice daily during their hospitalisation, with measured primary outcomes including partial pressure of oxygen, oxygen saturation, respiratory rate and type, days in hospital, and survival to discharge.

DISCUSSION

The proposed protocol aims to provide a practical guideline for applying HFNO to dogs hospitalised due to pneumonia. The protocol could enable more efficient and well-tolerated oxygenation than traditional methods, thus hastening recovery and improving survival of pneumonia patients.

Ultrasound-assessed lung aeration, oxygenation and respiratory care in neonatal bile acid pneumonia: A nested case-control study

AIM

Neonatal bile acid pneumonia (NBAP) occurs in neonates following obstetric cholestasis. We aimed to study the lung aeration and respiratory support of NBAP.

METHODS

Nested, case/control study enrolling age-matched neonates with NBAP, respiratory distress syndrome (RDS) or transient tachypnoea (TTN). Lung aeration and oxygenation were assessed with lung ultrasound score, oxygenation index and SpO2 /FiO2 .

RESULTS

Nineteen, 22 and 25 neonates with NBAP, RDS and TTN, respectively were studied (mean gestational age = 33 (2.2) weeks, 30 (45.5%) males). Upon admission, RDS patients had the worst lung ultrasound score (p = 0.022) and oxygenation index (p = 0.001), while NBAP and TTN neonates had similar values. At the worst time-point, NBAP and RDS patients showed similar oxygenation index (NBAP: 4.6 [2], RDS: 5.7 [3]) and SpO2 /FiO2 (NBAP: 3.1 [1.1], RDS: 2.7 [1]) which were worse than those of TTN patients (oxygenation index: p = 0.015, SpO2 /FiO2 : p = 0.001). RDS neonates needed the longest continuous positive airway pressure and highest mean airway pressure, but NBAP neonates needed invasive ventilation (26.3%, p = 0.01) and surfactant (31.6%, p = 0.003) more often than TTN patients who never needed these.

CONCLUSION

NBAP was a mild disorder in the first hours of life but subsequently worsened and became similar to RDS.