C反应蛋白在社区获得性肺炎诊断中的意义

目的研究C反应蛋白(C-reative protein,CRP)在社区获得性肺炎诊断中的意义。方法选择2009年8月—2012年8月收治的社区获得性肺炎患者120例作为观察组,同时,随机抽取80名健康体检者作为对照组,两组均于入院24 h内清晨空腹抽取静脉血,分离血清,测定WBC;每日测量体温3⁴次,取其平均值;采用上海蓝怡科技有限公司的试剂盒,用乳胶免疫比浊法测定血清CRP,CRP的正常上限为8 mg/L。计量资料采用t检验,计数资料采用χ2检验,P<0.05为差异有统计学意义。结果观察组CRP>8 mg/L者占95.0%,WBC>10×109/L者占20.0%,体温>36.8℃者占71.7%;对照组CRP、WBC、体温均正常。观察组CRP、WBC、体温分别为(48.31±20.34)mg/L、(9.88±2.34)×109/L、(38.10±0.62)℃,对照组分别为(4.62±2.17)mg/L、(5.34±1.29)×109/L、(36.83±0.15)℃,两组比较差异均有统计学意义(均P<0.05)。结论CRP是辅助诊断社区获得性肺炎有效、敏感的指标,具有重要的临床意义。     

C-反应蛋白在老年社区获得性肺炎与医院获得性肺炎中的比较研究

目的 分析血清C-反应蛋白(CRP)水平在老年不同病原菌肺部感染中的诊断作用.方法 对医院的98例社区获得性肺炎(CAP)、128例医院获得性肺炎(HAP)住院患者血中CRP、白细胞(WBC)、中性粒细胞(N)进行测定,并对痰标本进行病原菌分离鉴定.结果 CAP、HAP患者血中CRP水平分别为(79.8±16.2) mg/L和(46.4±8.4)mg/L,两组间差异有统计学意义(P＜0.01),而WBC、N则无明显差异;CAP患者病原菌检出率为43.88％,以革兰阳性球菌为主占27.55％,HAP患者病原菌检出率为63.28％,以革兰阴性杆菌为主占56.25％,两组患者的病原菌检出率、构成比差异均有统计学意义(P＜0.01).结论 CAP患者CRP水平显著高于HAP患者,两组患者感染的病原菌存在显著性差异,测定CRP水平有助于区分两组患者,指导临床合理选用抗菌药物.     

A systematic review classifies sources of bias and variation in diagnostic test accuracy studies

ObjectiveTo classify the sources of bias and variation and to provide an updated summary of the evidence of the effects of each source of bias and variation.Study Design and SettingWe conducted a systematic review of studies of any design with the main objective of addressing bias or variation in the results of diagnostic accuracy studies. We searched MEDLINE, EMBASE, BIOSIS, the Cochrane Methodology Register, and Database of Abstracts of Reviews of Effects (DARE) from 2001 to October 2011. Citation searches based on three key papers were conducted, and studies from our previous review (search to 2001) were eligible. One reviewer extracted data on the study design, objective, sources of bias and/or variation, and results. A second reviewer checked the extraction.ResultsWe summarized the number of studies providing evidence of an effect arising from each source of bias and variation on the estimates of sensitivity, specificity, and overall accuracy.ConclusionsWe found consistent evidence for the effects of case–control design, observer variability, availability of clinical information, reference standard, partial and differential verification bias, demographic features, and disease prevalence and severity. Effects were generally stronger for sensitivity than for specificity. Evidence for other sources of bias and variation was limited.     

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

BackgroundCommunity-acquired pneumonia (CAP) is associated with significant disease burden in adults but has not been measured uniformly. Reconciling differences across studies is critical for understanding the true burden of CAP.MethodsWe performed a systematic literature review of the incidence of hospitalized CAP among US adults and described the impact of key study characteristics on these estimates.ResultsAfter review of 8361 articles as of January 31, 2019, we identified 28 studies with 41 unique estimates of hospitalized CAP incidence. Among adults ≥65 years of age, annual rates of hospitalized CAP ranged from 847 to 3500 per 100,000 persons with median = 1830. Rates were lower in studies that excluded patients with healthcare-associated (but community-onset) pneumonia (HCAP; median = 2003 vs 1286; P = 0.02) or immunocompromising conditions (median = 1895 vs 1409; P = 0.27) compared to those that did not. Rates of CAP were also lower in studies that used more restrictive criteria for diagnosing pneumonia (eg, pneumonia coded in any diagnosis position [median = 2270] vs pneumonia coded in the first position only [median = 1375] in studies of administrative claims; P = 0.02). For adults <65 years of age, rates of CAP were lower (range: 89 to 1138 per 100,000; median = 199).ConclusionsCAP causes a significant disease burden among adults, particularly among those ≥65 years of age. Commonly-applied exclusion criteria (eg, persons with HCAP or immunocompromising conditions) or restrictive case definitions (eg, only including pneumonias coded in the primary diagnosis position) have led to systematic underestimation of CAP incidence in many previous studies. In studies that did not apply these restrictive criteria, the rate of hospitalization was approximately 2000 per 100,000 annually. Understanding the true burden of adult CAP is critical for highlighting the ongoing need for expanded prevention programs, including vaccination.     

Impact of PCV13 on community-acquired pneumonia by C-reactive protein and procalcitonin levels in children

BackgroundMany countries have observed an early and strong impact of implementation of the 13-valent pneumococcal conjugate vaccine (PCV13) on community-acquired pneumonia (CAP). High levels of C-reactive protein (CRP) and procalcitonin (PCT) are considered biomarkers of bacterial infection (particularly infection due to pneumococcus); therefore, PCV13 implementation should have different effectiveness on CAP depending on the levels of these two biomarkers. To demonstrate this assumption, we analyzed the evolution of number of CAP cases seen in pediatric emergency departments in France after PCV13 implementation (in 2010) by levels of these two biomarkers.MethodsFrom June 2009 to May 2015, 8 pediatric emergency units prospectively enrolled all children (1 month to 15 years) with radiologically confirmed CAP.ResultsA cohort of 9586 children with CAP was enrolled (median age 3 years). CAP with pleural effusion (PE-CAP) and proven pneumococcal pneumonia (PP-CAP) accounted for 5.5% and 2.0% of cases. During the study period, the number of cases of overall CAP decreased by 25.4%, hospitalized CAP by 30.5%, PE-CAP by 63.4%, CAP with CRP level ≥ 100 mg/L by 50.9%, CAP with PCT level ≥ 4 ng/L by 60.4% and PP-CAP by 86.4%. We found no change in number of cases of CAP with low levels of CRP (<20 or <40 mg/L) or PCT (<0.5 ng/mL). The number of cases of CAP overall increased (20.0%) in the last year of the study as compared with the preceeding year but not cases with CRP level ≥ 100 mg/L and/or PCT level ≥ 4 ng/mL.ConclusionPCV13 implementation has had a strong impact on number of CAP cases with high levels of CRP and/or PCT in children but no impact on that with low levels of these two biomarkers. Five years after PCV13 implementation, a sustained reduction in CAP cases is observed.     

Socioeconomic and racial/ethnic differentials of C-reactive protein levels: a systematic review of population-based studies

Background  

Socioeconomic and racial/ethnic factors strongly influence cardiovascular disease outcomes and risk factors. C-reactive protein (CRP), a non-specific marker of inflammation, is associated with cardiovascular risk, and knowledge about its distribution in the population may help direct preventive efforts. A systematic review was undertaken to critically assess CRP levels according to socioeconomic and racial/ethnic factors.     

社区获得性肺炎抗感染疗效及降钙素原和超敏C-反应蛋白的水平变化研究

目的探讨社区获得性肺炎(CAP)的抗感染疗效,观察炎症因子降钙素原(PCT)和超敏C-反应蛋白(hsCRP)在抗感染治疗前后的水平变化规律。方法选取2015年1-12月医院收治的死亡风险中等的CAP患者60例,依据抗感染方式的不同,分为左氧氟沙星组30例和β-内酰胺类联合阿奇霉素组(联合治疗组)30例,监测患者入院时、治疗期间生命体征变化,以及入院第3天及第5天血常规、血hs-CRP和PCT水平,比较两组患者治疗前后生命体征、血常规、PCT、hs-CRP、平均住院时间的差异。结果两组患者在性别、年龄及入院时生命体征(体温、呼吸、心率)方面比较,差异均无统计学意义(P>0.05);随着抗感染时间的延长,左氧氟沙星组患者体温恢复正常时间短于联合治疗组(P<0.05),其余生命体征指标恢复正常时间差异无统计学意义;两组患者入院时血常规、hs-CRP和PCT水平比较差异无统计学意义,入院第3天左氧氟沙星组较联合治疗组在白细胞计数(WBC)、中性粒细胞、单核细胞恢复正常的百分率比较,差异均有统计学意义(P<0.05);入院第5天时hs-CRP恢复正常的百分率高于联合治疗组(P<0.05)。结论与β-内酰胺类联合阿奇霉素治疗相比,左氧氟沙星治疗中度CAP患者的临床疗效似乎更好,多伴有血白细胞和炎症因子hs-CRP的更多改善。     

Screening accuracy for late-life depression in primary care: a systematic review

OBJECTIVE: To determine the accuracy of depression screening instruments for older adults in primary care. STUDY DESIGN: Systematic review. DATA SOURCES: MEDLINE, PsycINFO (search dates 1966 to January 2002), and the Cochrane database on depression, anxiety and neurosis. We also searched the second Guide to Clinical Preventive Services, the 1993 Agency for Health Care Policy and Research Clinical Practice Guideline on Depression, and recent systematic reviews. Hand-checking of bibliographies and extensive peer review were also used to identify potential articles. OUTCOMES MEASURED: A predefined search strategy targeted only studies of adults aged 65 years or older in primary care or community settings, including long-term care. Articles were included in this review if they reported original data and tested depression screening instruments against a criterion standard, yielding sensitivity and specificity. RESULTS: Eighteen articles met criteria and are included in this review, representing 9 different screening instruments. The most commonly evaluated were the Geriatric Depression Scale (30- and 15-item versions), the Center for Epidemiologic Studies Depression Scale, and the SelfCARE(D). Differences in the performance of these 3 instruments were minimal; sensitivities ranged from 74% to 100% and specificities ranged from 53% to 98%. CONCLUSIONS: Accurate and feasible screening instruments are available for detecting late-life depression in primary care. More research is needed to determine the accuracy of depression screening instruments for demented individuals, and for those with subthreshold depressive disorders.     

Ambient particulate air pollution and circulating C-reactive protein level: A systematic review and meta-analysis

BackgroundAmbient particulate air pollution is a major threat to the cardiovascular health of people. Inflammation is an important component of the pathophysiological process that links air pollution and cardiovascular disease (CVD). A classical marker of inflammation—C-reactive protein (CRP), has been recognized as an independent predictor of CVD risk. Exposure to ambient particulate matter (PM) may cause systemic inflammatory response but its association with CRP has been inconsistently reported.ObjectivesTo estimate the potential effects of short-term and long-term exposures to ambient particulate air pollution on circulating CRP level based on previous epidemiological studies.MethodsA systematic literature search of PubMed, Web of Science, Embase, and Scopus databases for publications up to January 2018 was conducted for studies reporting the association between ambient PM (PM_2.5 or PM₁₀, or both) and circulating CRP level. We performed a meta-analysis for the associations reported in individual studies using a random-effect model and evaluated the effect modification by major potential modifiers.ResultsThis meta-analysis comprised data from 40 observational studies conducted on 244,681 participants. These included 32 (27 PM_2.5 studies and 13 PM₁₀ studies) and 11 (9 PM_2.5 studies and 5 PM₁₀ studies) studies that investigated the associations of CRP with short-term and long-term exposure to particulate air pollution, respectively. A 10 μg/m³ increase in short-term exposure to PM_2.5 and PM₁₀ was associated with increases of 0.83 % (95% CI: 0.30%, 1.37%) and 0.39% (95% CI: -0.04%, 0.82%) in CRP level, respectively, and a 10 μg/m³ increase in long-term exposure to PM_2.5 and PM₁₀ was associated with much higher increases of 18.01% (95% CI: 5.96%, 30.06%) and 5.61% (95% CI: 0.79%, 10.44%) in CRP level, respectively. The long-term exposure to particulate air pollution was more strongly associated with CRP level than short-term exposure and PM_2.5 had a greater effect on CRP level than PM₁₀.ConclusionExposure to ambient particulate air pollution is associated with elevated circulating CRP level suggesting an activated systemic inflammatory state upon exposure, which may explain the association between particulate air pollution and CVD risk.     

Antimicrobial drug prescribing for pneumonia in ambulatory care

To determine patterns and predictors of antimicrobial drug use for outpatients with community-acquired pneumonia, we examined office visit and pharmacy claims data of 4 large third-party payer organizations from 2000 to 2002. After patients with coexisting conditions were excluded, 4,538 patients were studied. Despite lack of coexisting conditions, fluoroquinolone use was commonly observed and increased significantly (p < 0.001) from 2000 to 2002 (24%-39%), while macrolide use decreased (55%-44%). Increased age correlated with increased fluoroquinolone use: 18-44 years (22%), 45-64 years (33%), and > or =65 years (40%) (p < 0.001). Increased use of fluoroquinolones occurred in healthy young and old patients alike, which suggests a lack of selectivity in reserving fluoroquinolones for higher risk patients. Clear and consistent guidelines are needed to address the role of fluoroquinolones in treatment of outpatient community-acquired pneumonia.     

Acute community-acquired pneumonia. A review of clinical trials

Optimal antibiotic treatment of community-acquired pneumonia (CAP) remains controversial. The clinical impact of S. pneumoniae resistance to macrolides is well documented. By contrast high dosage amoxicillin (1 g tid) remains active against such strains and no failure has been reported. The aim of this paper was to review clinical trials in community-acquired pneumonia, published from January 1, 1999, to December 31, 2005. One hundred seventy-three articles were collected, using Medline, 35 of which were analyzed, and 16 finally used. Telithromycin and pristinamycin may be used in mild to moderate CAP. Anti-pneumococcal fluoroquinolones such as levofloxacin and moxifloxacin may be used in at risk patients, but levofloxacin has only been investigated in patients with severe CAP and patients with Legionnaire's disease. Amoxicillin 1 g tid remains the drug of choice for pneumococcal CAP.     

A systematic review of observational studies of adult home care

The home‐care workforce is in high demand globally. Home‐care workers provide care for people at home, including practical and personal care, as well as other tasks such as medication management. We conducted a systematic review with the aims of understanding methods of observation that have been employed to study home care and to explore how these methods have enabled researchers to understand the quality of home care. We searched the literature using PubMed and CINAHL databases in May 2018, with no limits applied to date of publication. We searched for MeSH terms of ‘Home Care Services’, ‘Home Health Care’, ‘Home Nursing’ and ‘Observation*’. Across 15 eligible studies, the types of observation methods employed were categorised as structured, guided and unstructured. The characteristics of these methods, such as the level of participation adopted by the observer, varied across the studies. Three themes were developed through a narrative synthesis of the included studies’ findings: ‘The impact of care delivery and organisational factors’, ‘Observing relationships and communications’, and ‘People and places behind closed doors’. We conclude that methods of observation are a fairly novel, yet rich and meaningful way of exploring home‐care practice. Researchers undertaking observations should consider elements such as the number of researchers observing and the potential for variations, how and when to record the observations, possible triangulation of data, the researcher's reflective stance as an observer, as well as ethical considerations.     

Locating systematic reviews of test accuracy studies: how five specialist review databases measure up

OBJECTIVES: The aim of this study was to examine location of systematic reviews of test accuracy in five specialist review databases: York CRD's DARE and HTA databases, Medion (University of Maastricht), C-EBLM (International Federation of Clinical Chemistry), and the ARIF in-house database (University of Birmingham). METHODS: Searches were limited to the period 1996-2006. Test accuracy reviews were located using in-house diagnostic search filters and with help from database producers where databases were not confined to test accuracy reviews. References were coded according to disease area, review purpose, and test application. Ease of use, volume, overlap, and content of databases was noted. RESULTS: A large degree of overlap existed between databases. Medion contained the largest number (n = 672) and the largest number of unique (n = 328) test accuracy references. A combination of three databases identified only 76% of test reviews. All databases were rated as easy to search but varied with respect to timeliness and compatibility with reference management software. Most reviews evaluated test accuracy (85%) but the HTA database had a larger proportion of cost-effectiveness and screening reviews and C-EBLM more reviews addressing early test development. Most reviews were conducted in secondary care settings. CONCLUSIONS: Specialist review databases offer an essential addition to general bibliographic databases where application of diagnostic method filters can compromise search sensitivity. Important differences exist between databases in terms of ease of use and content. Our findings raise the question whether the current balance of research setting, in particular the predominance of research on tests used in secondary care, matches the needs of decision makers.     

Reporting studies of diagnostic accuracy: the STARD initiative

Family Practice tries to keep its readers abreast of good practicein medical publishing. We encourage the reporting of randomizedcontrolled trials in a format which     

Racial variations in processes of care for patients with community-acquired pneumonia

Background

Patients hospitalized with community acquired pneumonia (CAP) have a substantial risk of death, but there is evidence that adherence to certain processes of care, including antibiotic administration within 8 hours, can decrease this risk. Although national mortality data shows blacks have a substantially increased odds of death due to pneumonia as compared to whites previous studies of short-term mortality have found decreased mortality for blacks. Therefore we examined pneumonia-related processes of care and short-term mortality in a population of patients hospitalized with CAP.

Methods

We reviewed the records of all identified Medicare beneficiaries hospitalized for pneumonia between 10/1/1998 and 9/30/1999 at one of 101 Pennsylvania hospitals, and randomly selected 60 patients at each hospital for inclusion. We reviewed the medical records to gather process measures of quality, pneumonia severity and demographics. We used Medicare administrative data to identify 30-day mortality. Because only a small proportion of the study population was black, we included all 240 black patients and randomly selected 720 white patients matched on age and gender. We performed a resampling of the white patients 10 times.

Results

Males were 43% of the cohort, and the median age was 76 years. After controlling for potential confounders, blacks were less likely to receive antibiotics within 8 hours (odds ratio with 95% confidence interval 0.6, 0.4–0.97), but were as likely as whites to have blood cultures obtained prior to receiving antibiotics (0.7, 0.3–1.5), to have oxygenation assessed within 24 hours of presentation (1.6, 0.9–3.0), and to receive guideline concordant antibiotics (OR 0.9, 0.6–1.7). Black patients had a trend towards decreased 30-day mortality (0.4, 0.2 to 1.0).

Conclusion

Although blacks were less likely to receive optimal care, our findings are consistent with other studies that suggest better risk-adjusted survival among blacks than among whites. Further study is needed to determine why this is the case.     

Efficacy of 23-valent pneumococcal polysaccharide vaccine in preventing community-acquired pneumonia among immunocompetent adults: A systematic review and meta-analysis of randomized trials

BackgroundData on the efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPV-23) in preventing adult community-acquired pneumonia (CAP) among the target population of individuals aged over 65 years and high-risk individuals aged 19–64 years are conflicting. As the Advisory Committee on Immunization Practices (ACIP) has recently demonstrated PPV-23 is likely beneficial to immunocompromised adults by the Grading, Assessment, Development, and Evaluation (GRADE) framework, we conducted meta-analysis to examine its efficacy in an immunocompetent population.MethodsWe searched the PUBMED, EMBASE, and Cochrane Library databases for randomized trials. Overall relative risks (RRs) with 95% confidential intervals (CIs) were calculated, and the Cochrane Q test (p, I²) was performed. Outcomes were assessed by the GRADE framework.ResultsSeven randomized trials involving 156,010 participants were included in this meta-analysis. High-quality evidence revealed that PPV-23 was weakly associated with the prevention of all-cause pneumonia ([RR] 0.87, [95%CI] 0.76–0.98, p = 0.11, I² = 43%), especially among the target population ([RR] 0.72, [95%CI] 0.69–0.94, p = 0.58 I² = 0%), the elderly group aged over 40 years ([RR] 0.80, [95%CI] 0.69–0.94) and the Japanese population ([RR] 0.72, [95%CI] 0.59–0.88, p = 0.24, I² = 30%). The target population included adults aged over 65 years and patients at high risk of pneumonia due to chronic lung disease, chronic obstructive pulmonary disease or living in a nursing home. Protective trends of PPV-23 in the outcomes of pneumococcal pneumonia ([RR] 0.54, [95%CI] 0.18–1.65, p = 0.01, I² = 77%) and mortality due to pneumonia ([RR] 0.67, [95%CI] 0.43–1.04, p = 0.67, I² = 0%) were observed, although the results were statistically insignificant, possibly due to the small number of trials included. PPV-23 did not prevent all-cause mortality ([RR] 1.04, [95%CI] 0.87–1.24, p = 0.95, I² = 0%).ConclusionsPPV-23 provided weak protection against all-cause pneumonia in an immunocompetent population, especially among the target population. The additional benefit of PPV-23 in preventing CAP further supports its application in the target population.     

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs

Background

Acute urinary tract infections (UTI) are one of the most common bacterial infections among women presenting to primary care. However, there is a lack of consensus regarding the optimal reference standard threshold for diagnosing UTI. The objective of this systematic review is to determine the diagnostic accuracy of symptoms and signs in women presenting with suspected UTI, across three different reference standards (10² or 10³ or 10⁵ CFU/ml). We also examine the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making.

Methods

Searches were performed through PubMed (1966 to April 2010), EMBASE (1973 to April 2010), Cochrane library (1973 to April 2010), Google scholar and reference checking. Studies that assessed the diagnostic accuracy of symptoms and signs of an uncomplicated UTI using a urine culture from a clean-catch or catherised urine specimen as the reference standard, with a reference standard of at least ≥ 10² CFU/ml were included. Synthesised data from a high quality systematic review were used regarding dipstick results. Studies were combined using a bivariate random effects model.

Results

Sixteen studies incorporating 3,711 patients are included. The weighted prior probability of UTI varies across diagnostic threshold, 65.1% at ≥ 10² CFU/ml; 55.4% at ≥ 10³ CFU/ml and 44.8% at ≥ 10² CFU/ml ≥ 10⁵ CFU/ml. Six symptoms are identified as useful diagnostic symptoms when a threshold of ≥ 10² CFU/ml is the reference standard. Presence of dysuria (+LR 1.30 95% CI 1.20-1.41), frequency (+LR 1.10 95% CI 1.04-1.16), hematuria (+LR 1.72 95%CI 1.30-2.27), nocturia (+LR 1.30 95% CI 1.08-1.56) and urgency (+LR 1.22 95% CI 1.11-1.34) all increase the probability of UTI. The presence of vaginal discharge (+LR 0.65 95% CI 0.51-0.83) decreases the probability of UTI. Presence of hematuria has the highest diagnostic utility, raising the post-test probability of UTI to 75.8% at ≥ 10² CFU/ml and 67.4% at ≥ 10³ CFU/ml. Probability of UTI increases to 93.3% and 90.1% at ≥ 10² CFU/ml and ≥ 10³ CFU/ml respectively when presence of hematuria is combined with a positive dipstick result for nitrites. Subgroup analysis shows improved diagnostic accuracy using lower reference standards ≥ 10² CFU/ml and ≥ 10³ CFU/ml.

Conclusions

Individual symptoms and signs have a modest ability to raise the pretest-risk of UTI. Diagnostic accuracy improves considerably when combined with dipstick tests particularly tests for nitrites.