Usefulness of a semi-quantitative procalcitonin test and the A-DROP Japanese prognostic scale for predicting mortality among adults hospitalized with community-acquired pneumonia

Background and objective: The solid‐phase immunoassay, semi‐quantitative procalcitonin (PCT) test (B R A H M S PCT‐Q) can be used to rapidly categorize PCT levels into four grades. However, the usefulness of this kit for determining the prognosis of adult patients with community‐acquired pneumonia (CAP) is unclear. Methods: A prospective study was conducted in two Japanese hospitals to evaluate the usefulness of this PCT test in determining the prognosis of adult patients with CAP. The accuracy of the age, dehydration, respiratory failure, orientation disturbance, pressure (A‐DROP) scale proposed by the Japanese Respiratory Society for prediction of mortality due to CAP was also investigated. Hospitalized CAP patients (n = 226) were enrolled in the study. Comprehensive examinations were performed to determine PCT and CRP concentrations, disease severity based on the A‐DROP, pneumonia severity index (PSI) and confusion, urea, respiratory rate, blood pressure, age ≥65 (CURB‐65) scales and the causative pathogens. The usefulness of the biomarkers and prognostic scales for predicting each outcome were then examined. Results: Twenty of the 170 eligible patients died. PCT levels were strongly positively correlated with PSI (ρ = 0.56, P < 0.0001), A‐DROP (ρ = 0.61, P < 0.0001) and CURB‐65 scores (ρ = 0.58, P < 0.0001). The areas under the receiver operating characteristic curves (95% CI) for prediction of survival, for CRP, PCT, A‐DROP, CURB‐65, and PSI were 0.54 (0.42–0.67), 0.80 (0.70–0.90), 0.88 (0.82–0.94), 0.88 (0.82–0.94), and 0.89 (0.85–0.94), respectively. The 30‐day mortality among patients who were PCT‐positive (≥0.5 ng/mL) was significantly higher than that among PCT‐negative patients (log–rank test, P < 0.001). Conclusions: The semi‐quantitative PCT test and the A‐DROP scale were found to be useful for predicting mortality in adult patients with CAP.     

Use of the ‘CURB 65’ score in hospital practice

Background: The ‘CURB 65’ score is a simple well‐validated tool for the assessment of severity in community acquired pneumonia (CAP). Whether it is used routinely is unknown. The aim of this study was to determine the frequency of use of the score in routine hospital practice and correlate this with clinical decision making and patient outcome. Methods: Retrospective cohort study of all patients with CAP (n= 174) presenting in three winter months. Demographic and clinical outcome data were recorded and comparisons were made between those patients who had score applied on admission with those that did not. A CURB 65 score was assigned to all patients using data from the patient record, and admission decisions were compared. Results: Only 9 (5.2%) CAP patients had the ‘CURB 65’ score applied at admission. The overall mortality rate was 3.4%. On applying a score to all cases retrospectively, appropriate admission decisions were made for patients with moderate or severe pneumonia and outcome was in accordance with published results. However, 23 (13%) patients age <65 with mild CAP and no comorbidities were admitted in spite of guideline recommendation for community care. Conclusions: These data demonstrate that clinical decision making in respect of moderate or severe CAP is the same whether or not a pneumonia severity score is applied. However, routine use of the score will identify patients with mild CAP thus potentially reducing unnecessary admission.     

Australasian respiratory and emergency physicians do not use the pneumonia severity index in community‐acquired pneumonia

Background and objective: The value of community‐acquired pneumonia (CAP) severity scoring tools is almost exclusively reliant upon regular and accurate application in clinical practice. Until recently, the Australasian Therapeutic Guidelines has recommended the use of the Pneumonia Severity Index (PSI) in spite of poor user‐friendliness. Methods: Electronic and postal survey of respiratory and emergency medicine physician and specialist registrar members of the Royal Australasian College was undertaken to assess the use of the PSI and the accuracy of its application to hypothetical clinical CAP scenarios. The confusion, urea, respiratory rate, blood pressure, age 65 or older (CURB‐65) score was also assessed as a simpler alternative. Results: Five hundred thirty‐six (228 respiratory, 308 emergency) responses were received. Only 12% of respiratory and 35% of emergency physicians reported using the PSI always or frequently. The majority were unable to accurately approximate PSI scores, with significantly fewer respiratory than emergency physicians recording accurate severity classes (11.8% vs 21%, OR 0.50, 95% CI: 0.37–0.68, P < 0.0001). In contrast, significantly more respiratory physicians were able to accurately calculate the CURB‐65 score (20.4% vs 15%, OR 1.45, 95% CI: 1.10–1.91, P = 0.006). Conclusions: Australasian specialist physicians primarily responsible for the acute management of CAP report infrequent use of the PSI and are unable to accurately apply its use to hypothetical scenarios. Furthermore, respiratory and emergency physicians contrasted distinctly in their use and application of the two commonest severity scoring systems—the recent recommendation of two further alternative scoring tools by Australian guidelines may add to this confusion. A simple, coordinated approach to pneumonia severity assessment across specialties in Australasia is needed.     

Prognostic value of procalcitonin in pneumonia: A systematic review and meta‐analysis

This meta‐analysis was performed to determine the accuracy of procalcitonin (PCT) in predicting mortality in pneumonia patients with different pathogenic features and disease severities. A systematic search of English‐language articles was performed using PubMed, Embase, Web of Knowledge and the Cochrane Library to identify studies. The diagnostic value of PCT in predicting prognosis was determined using a bivariate meta‐analysis model. The Q‐test and I² index were used to test heterogeneity. A total of 21 studies comprising 6007 patients were included. An elevated PCT level was a risk factor for death from community‐acquired pneumonia (CAP) (risk ratio (RR) 4.38, 95% confidence interval (CI) 2.98–6.43), particularly in patients with a low CURB‐65 score. The commonly used cut‐off, 0.5 ng/mL, had low sensitivity (SEN) and was not able to identify patients at high risk of dying. Furthermore, the PCT assay with functional SEN <0.1 ng/mL was necessary to predict mortality in CAP in the clinic. For critically ill patients, an elevated PCT level was associated with an increased risk of mortality (RR 4.18, 95% CI: 3.19–5.48). The prognostic performance was nearly equal between patients with ventilator‐associated pneumonia (VAP) and patients with CAP.     

Predicting mortality among older adults hospitalized for community-acquired pneumonia: an enhanced confusion, urea, respiratory rate and blood pressure score compared with pneumonia severity index

Background and objective: Pneumonia Severity Index (PSI) predicts mortality better than C onfusion, U rea >7 mmol/L, R espiratory rate >30/min, low Bl ood pressure: diastolic blood pressure <60 mm Hg or systolic blood pressure <90 mm Hg, and age >65 years (CURB‐65) for community‐acquired pneumonia (CAP) but is more cumbersome. The objective was to determine whether CURB enhanced with a small number of additional variables can predict mortality with at least the same accuracy as PSI. Methods: Retrospective review of medical records and administrative data of adults aged 55 years or older hospitalized for CAP over 1 year from three hospitals. Results: For 1052 hospital admissions of unique patients, 30‐day mortality was 17.2%. PSI class and CURB‐65 predicted 30‐day mortality with area under curve (AUC) of 0.77 (95% confidence interval (CI): 0.73–0.80) and 0.70 (95% CI: 0.66–0.74) respectively. When age and three co‐morbid conditions (metastatic cancer, solid tumours without metastases and stroke) were added to CURB, the AUC improved to 0.80 (95% CI: 0.77–0.83). Bootstrap validation obtained an AUC estimate of 0.78, indicating negligible overfitting of the model. Based on this model, a clinical score (enhanced CURB score) was developed that had possible values from 5 to 25. Its AUC was 0.79 (95% CI: 0.76–0.83) and remained similar to that of PSI class. Conclusions: An enhanced CURB score predicted 30‐day mortality with at least the same accuracy as PSI class did among older adults hospitalized for CAP. External validation of this score in other populations is the next step to determine whether it can be used more widely.     

高龄重症社区获得性肺炎并心血管事件患者预后不良因素分析

目的:分析高龄重症社区获得性肺炎(CAP)合并心血管事件患者预后不良因素,探讨临床诊疗策略。方法:将116例高龄重症CAP并发心血管事件患者按照住院30d内的预后分为治愈出院组(54例)和预后不良组(62例)。分析2组患者性别、年龄、入院时CURB65评分(包括意识障碍、尿素氮、呼吸频率、血压、年龄)、肺炎严重指数(PSI评分)及CRB65评分(包括意识障碍、呼吸频率、血压、年龄)、重症肺炎评判主要标准及次要标准构成情况、住院前心血管事件发生史、住院期间心血管事件类别、辅助治疗措施、初始疗效、并发症情况等,将组间差异有统计学意义的指标纳入多因素Logistic回归分析,分析高龄重症CAP并心血管事件患者预后不良的危险因素。结果:住院期间新发心律失常47例(40. 52%)、急性心肌梗死33例(28. 45%)、心绞痛21例(18. 10%)、急性心力衰竭15例(12. 93%)。2组患者年龄、入院时CURB65评分、PSI评分、CRB65评分、住院前心血管事件发生史、住院期间心血管事件类别、初始疗效比较,差异有统计学意义(均P 0. 05)。多因素Logistic分析显示,年龄(OR=4. 156)、入院时CURB65评分5分(OR=3. 632)、PSIⅤ级(OR=4. 589)、CRB65评分4分(OR=2. 445)、住院前有心血管事件史(OR=4. 625)、住院期间发生急性心肌梗死(OR=4. 514)、初始治疗无效(OR=3. 422)为高龄重症CAP并发心血管事件患者预后不良的危险因素。结论:高龄重症CAP并发心血管事件患者预后不良率高,临床应采取措施加以防范,降低不良事件风险率,改善患者预后。     

Pentraxin 3 predicts complicated course of febrile neutropenia in haematological patients, but the decision level depends on the underlying malignancy

Objectives: This study aimed at assessing the cut‐off levels for pentraxin 3 (PTX3) in predicting complications of neutropenic fever (bacteraemia, septic shock) in haematological patients. Methods: A prospective study during 2006–2009 was performed at haematology ward in Kuopio University Hospital. A patient was eligible for the study if having neutropenic fever after intensive therapy for acute myeloid leukaemia (AML) (n = 32) or non‐Hodgkin lymphoma (NHL) (n = 35). Blood cultures were taken, and maximal PTX3 and C‐reactive protein (CRP) were evaluated during d0 to d3 from the beginning of fever onset. Results: The level of PTX3 was associated with both the underlying malignancy and the presence of complications, with highest level in NHL patients with complicated course of febrile neutropenia and lowest in AML patients with non‐complicated course. The cut‐off level of PTX3 to predict complications was ten‐fold in patients with NHL (115 μg/L) in comparison with patients with AML (11.5 μg/L). In combined analysis based on separate cut‐offs, PTX3 predicted complications of febrile neutropenia with sensitivity of 0.86, specificity of 0.83, positive predictive value of 0.57 and negative predictive value of 0.96. Conclusions: PTX3 was superior to CRP in predicting complicated course of febrile neutropenia, but only when the effect of the underlying malignancy had been taken into account.     

CRB-65 predicts death from community-acquired pneumonia

OBJECTIVE: The study was performed to validate the CURB, CRB and CRB-65 scores for the prediction of death from community-acquired pneumonia (CAP) in both the hospital and out-patient setting. DESIGN: Data were derived from a large multi-centre prospective study initiated by the German competence network for community-acquired pneumonia (CAPNETZ) which started in March 2003 and were censored for this analysis in October 2004. SETTING: Out- and in-hospital patients in 670 private practices and 10 clinical centres. SUBJECTS: Analysis was done for n = 1343 patients (n = 208 out-patients and n = 1135 hospitalized) with all data sets completed for the calculation of CURB and repeated for n = 1967 patients (n = 482 out-patients and n = 1485 hospitalized) with complete data sets for CRB and CRB-65. INTERVENTION: None. 30-day mortality from CAP was determined by personal contacts or a structured interview. RESULTS: Overall 30-day mortality was 4.3% (0.6% in out-patients and 5.5% in hospitalized patients, P < 0.0001). Overall, the CURB, CRB and CRB-65 scores provided comparable predictions for death from CAP as determined by receiver-operator-characteristics (ROC) curves. However, in hospitalized patients, CRB misclassified 26% of deaths as low risk patients. Availability of the CRB-65 score (90%) was far superior to that of CURB (65%), due to missing blood urea nitrogen values (P < 0.001). CONCLUSIONS: Both the CURB and CRB-65 scores can be used in the hospital and out-patients setting to assess pneumonia severity and the risk of death. Given that the CRB-65 is easier to handle, we favour the use of CRB-65 where blood urea nitrogen is unavailable.     

血清血管生成素-2与老年人社区获得性肺炎严重程度的相关性研究

目的:探讨血清血管生成素-2(Ang-2)在老年社区获得性肺炎(CAP)患者中的表达,并评估其与CAP严重程度的相关性。方法:采用病例对照研究,选取老年CAP住院患者共118例,根据病情严重程度将所有患者分为普通肺炎组(67例)和重症肺炎组(51例),同时选取40例老年无肺炎健康体检者作为对照组。检测血清Ang-2、白...     

Prognostic value of C-reactive protein in parapneumonic effusions

Background and objective: Parapneumonic effusions (PPE) that require drainage are referred to as complicated parapneumonic effusions (CPPE). Following resolution of these effusions, residual pleural thickening (RPT) may persist. We hypothesize that the concentrations of CRP in pleural fluid (CRP_pf) and serum (CRP_ser) can be used to identify CPPE and to predict RPT. Methods: All patients with non‐purulent PPE, who were admitted to two tertiary hospitals during a 30‐month period, were enrolled in the study. Baseline CRP_pf and CRP_ser levels were compared between patients with complicated or uncomplicated PPE, as well as between patients with or without RPT of >10 mm, 6 months after discharge from hospital. Cut‐off values for identification of CPPE and prediction of RPT were determined by receiver operating characteristic curve analysis. Logistic regression analysis was performed to assess the association between CRP levels and RPT. Results: Fifty‐four patients were included in the study. Patients with CPPE (n = 23) had significantly higher levels of both CRP_pf and CRP_ser than those with uncomplicated PPE. For identification of CPPE, a CRP_pf level >78.5 mg/L and a CRP_ser level >83 mg/L gave 84% and 47% sensitivity, with 65% and 87% specificity, respectively. Classical criteria (pleural fluid pH <7.20, LDH >1000 IU/L, glucose <600 mg/L) were superior for this purpose. A combination of classical biomarkers with CRP levels using an ‘AND’ or ‘OR’ rule improved the positive and negative predictive values, respectively. CRP_ser was an independent predictor for development of RPT (adjusted OR 1.18). A CRP_ser level >150 mg/L had 91% specificity and 61% sensitivity for prediction of RPT. Conclusions: This study demonstrated the value of CRP_ser for prediction of RPT in patients with PPE. Moreover, when used in combination with classical biomarkers, CRP levels may be a useful adjunct for decision‐making in relation to treatment of patients with non‐purulent PPE.     

Community‐acquired pneumonia in older patients: Does age influence systemic cytokine levels in community‐acquired pneumonia?

Background and objective:   Community-acquired pneumonia (CAP) is a major cause of death in the elderly. The age-related increase in comorbid illnesses plays a part but the effect of aging on the immune response may be equally important. We aimed to evaluate patients with CAP for evidence of a muted response to infection in elderly patients admitted to hospital compared with a younger patient group.
Methods:   Patients with CAP admitted through the Emergency Department were recruited for this prospective observational study. Clinical data were collected at presentation. Severity of pneumonia was assessed using the British Thoracic Society confusion, urea nitrogen, respiratory rate, blood pressure (CURB) score, the Pneumonia Severity Index (PSI) and the systemic inflammatory response syndrome (SIRS) definition. IL-6 and IL-10 levels were measured within 24 h of admission.
Results:   Eighty patients were included in the study, of whom 38 (48%) were female. The median age was 74 years (range 18–95). Patients greater than 65 years of age had a lower incidence of chest pain and a higher incidence of altered mental status on presentation. CURB score and PSI were higher in the older patients. SIRS showed similar frequencies in both groups. IL-6 and IL-10 levels were similar in young (< 65 years), older (> 65 years) and very elderly (> 80 years) patients. This finding was not altered by severity of pneumonia.
Conclusions:   Age does not diminish the severity of illness scores in patients with CAP. There was no blunting of the systemic cytokine response with advanced age in this study.     

Role of procalcitonin and C-reactive protein in differentiation of mixed bacterial infection from 2009 H1N1 viral pneumonia

Please cite this paper as: Ahn et al. (2011) Role of procalcitonin and C‐reactive protein in differentiation of mixed bacterial infection from 2009 H1N1 viral pneumonia. Influenza and Other Respiratory Viruses 5(6), 398–403. Background Mixed bacterial infection is an important contributor to morbidity and mortality during influenza pandemics. We evaluated procalcitonin (PCT) and C‐reactive protein (CRP) in differentiating pneumonia caused by mixed bacterial and 2009 H1N1 influenza infection from 2009 H1N1 influenza infection alone. Methods Data were collected retrospectively over a 7‐month period during the 2009 H1N1 influenza pandemic. Patients visiting emergency department and diagnosed as community‐acquired pneumonia caused by 2009 H1N1 infection were included (n = 60). Results Mixed bacterial and viral infection pneumonia (n = 16) had significantly higher PCT and CRP levels than pneumonia caused by 2009 H1N1 influenza alone (n = 44, P = 0·019, 0·022 respectively). The sensitivity and specificity for detection of mixed bacterial infection pneumonia was 56% and 84% for PCT > 1·5 ng/ml, and 69% and 63% for CRP > 10 mg/dl. Using PCT and CRP in combination, the sensitivity and specificity were 50% and 93%, respectively. Conclusion Procalcitonin and CRP alone and their combination had a moderate ability to detect pneumonia of mixed bacterial infection during the 2009 H1N1 pandemic. Considering high specificity, combination of low CRP and PCT result may suggest that pneumonia is unlikely to be caused by mixed bacterial infection.     

Severity assessment criteria recommended by the British Thoracic Society (BTS) for community-acquired pneumonia (CAP) and older patients. Should SOAR (systolic blood pressure, oxygenation, age and respiratory rate) criteria be used in older people? A compilation study of two prospective cohorts

OBJECTIVES: To assess the usefulness of the British Thoracic Society guidelines for severity assessment of community-acquired pneumonia (CAP) in predicting mortality and to explore alternative criteria which could be more useful in older patients. DESIGN: Compilation study of two prospective observational cohorts. SETTING AND PARTICIPANTS: A University hospital in Norfolk, UK with a catchment population of 568,000. Subjects were 195 patients (median age = 77 years) who were included in two prospective studies of CAP. MAIN OUTCOME MEASURE: All-cause mortality occurring within the 6 week follow-up. RESULTS: sensitivity, specificity, positive and negative predictive values for study outcome using CURB and CURB-65 were assessed in 189 patients, and CRB-65 in 192 patients out of a total of 195 patients. Our results were comparable with the original study by Lim et al. Although CURB-65 and CRB-65 included age criteria, in effect they did not materially improve the specificity in predicting high-risk patients in both studies. We found that oxygenation measured by ventilation perfusion mismatch (PaO2:FiO2) was the best predictor of outcome in this slightly older cohort [odds ratio (OR) = 0.99 (0.98-0.99), P = 0.0001]. We derived a new set of criteria; SOAR (systolic blood pressure, oxygenation, age and respiratory rate) based on our findings. Their sensitivity, specificity, positive and negative predictive values were 81.0% (58.1-94.6), 59.3% (49.6-68.4), 27.0% (16.6-39.7) and 94.4% (86.2-98.4), respectively, confirming their comparability with existing criteria. CONCLUSIONS: Our Study confirms the usefulness of currently recommended severity rules for CAP in this older cohort. SOAR criteria may be useful as alternative criteria for a better identification of severe CAP in advanced age where both raised urea level above 7 mmol/l and confusion are common.     

Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia

PURPOSE: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores. SUBJECTS AND METHODS: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score <1 (51% [1635/3181]) or a CURB-65 score <2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P <0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score. CONCLUSIONS: The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.     

Mass spectrometry evaluation of the hepcidin‐25 assay in the differential diagnosis of iron deficiency anaemia with concurrent inflammation and anaemia of inflammation in elderly patients

In this study, mass spectrometry was used to evaluate the hepcidin‐25 assay in the differential diagnosis of iron deficiency anaemia with concurrent inflammation and anaemia of inflammation in elderly patients using the absence of stainable bone marrow iron as the gold standard criterion for iron deficiency (ID). In addition, correlation coefficients for hepcidin‐25 vs. haematimetric and biochemical iron parameters, and C‐reactive protein (CRP) were determined. The optimal cut‐off for hepcidin‐25 was 31.5 ng/mL corresponding to a sensitivity and specificity of 82% and 95%, respectively, for ID. For ferritin, a sensitivity and specificity of 70% and 100%, respectively, correspond to an optimal cut‐off of 41.5 μg/L. Receiver operating characteristics curve analysis revealed that mass spectrometry analysis of hepcidin‐25 does not appear to be superior to ferritin in the diagnosis of ID in elderly anaemic patients with concurrent inflammation. Hepcidin‐25 shows a strong positive correlation with ferritin, and also correlates positively with CRP, in this patient population.     

血清降钙素原预测社区获得性肺炎病情严重程度的临床研究

目的探讨血清降钙素原在评估社区获得性肺炎(CAP)病情严重程度的临床价值。方法收集2011年1月~2012年12月在西丽人民医院接受治疗的CAP患者80例,分≥65岁组50例;65岁组30例,评价两组患者血清降钙素原、C-反应蛋白、白细胞计数、CURB-65和肺炎严重程度指数(PSI)之间的相关性。结果血清降钙素原(PCT)与CURB-65、PSI在总体上具有正相关性。血清降钙素原和CURB-65在≥65岁组CAP中尤其具有显著的正相关(r=0.408)。C-反应蛋白或白细胞水平与CAP严重程度之间的相关性较低。结论血清降钙素原比C-反应蛋白、白细胞计数更有助于临床预测CAP的严重程度,尤其是对于年龄大于65岁的老年患者。     

Changes in modified Glasgow prognostic score after neoadjuvant chemotherapy is a prognostic factor in clinical stage II/III esophageal cancer

The inflammation‐based modified Glasgow prognostic score (mGPS) has been shown to be a prognostic factor for esophageal cancer, but its changes in relation to neoadjuvant chemotherapy (NAC) have never been discussed. The purpose of this study was to evaluate the potential prognostic role of mGPS with regard to NAC. mGPS was evaluated on the basis of admission blood samples taken before chemotherapy and before surgery. Patients with elevated C‐reactive protein (CRP) serum levels (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a score of 2, patients with elevated CRP serum levels without hypoalbuminemia were allocated a score of 1, and patients with normal CRP serum levels with or without hypoalbuminemia were allocated a score of 0. A total of 100 patients with clinical stage II/III squamous cell esophageal cancer, who underwent NAC and esophagectomy between January 2007 and August 2012, were investigated. From the multivariate analysis, the grade of response to chemotherapy and post‐NAC mGPS level was found to be independent prognostic factors. The overall survival rate was significantly higher in the conserved mGPS group than in the worse mGPS group (P = 0.030). Changes in mGPS during chemotherapy affected the prognosis of patients, and post‐NAC mGPS is an independent prognostic factor in patients with clinical stage II/III thoracic esophageal squamous cell cancer.     

Prospective comparison of prediction rules of mortality risk for CAP in a developing country.

SETTING: Aga Khan University Hospital, Karachi, Pakistan. OBJECTIVE: To prospectively compare 30-day mortality with CURB65 and CRB65 scores and the three mortality risk groups (low, intermediate and high) based on these scores in hospitalised patients with community-acquired pneumonia (CAP). DESIGN: Longitudinal observational cohort study of adult in-patients fulfilling the definition of CAP between October 2006 and May 2007. RESULTS: A total of 137 patients was included. The 30-day mortality was 13.1%. Areas under the receiver operating characteristic curve for CURB65 and CRB65 scores were respectively 0.863 and 0.835. Odds of death among patients in the high mortality risk group of CURB65 score was 15.4 and those of CRB65 was 11.1 compared with the low and intermediate mortality risk groups combined as reference. CURB65 and CRB65 scores classified 46% and 24.8% patients, respectively, into the low mortality risk group. Length of hospital stay increased with the CURB65 score-based mortality risk groups but not with those based on the CRB65 score. CONCLUSION: CURB65 and CRB65 scores showed no significant difference in predicting 30-day mortality. Both scores, and the CURB65 score in particular, categorised reasonable proportions of patients into the low mortality risk group who could be discharged from the emergency room and managed as out-patients.     

Predicting early mortality in acute exacerbation of chronic obstructive pulmonary disease using the CURB65 score

Background and Objective: Hospitalization for exacerbation of COPD is associated with a high risk of mortality. A risk‐prediction model using information easily obtained on admission could help to identify high‐risk individuals. The CURB65 score was developed to predict mortality risk in community acquired pneumonia. A retrospective study found that this score was also associated with mortality in COPD exacerbations. We conducted a prospective study to assess the utility of the CURB65 score in acute COPD exacerbations. Methods: Consecutive patients with physician diagnosed COPD exacerbations admitted to a public hospital during a 1‐year period were studied prospectively. The CURB65 scores were calculated from information obtained at initial hospital presentation. CURB65 = one point each for Confusion, Urea > 7 mmol/L, Respiratory rate ≥ 30/min, low Blood pressure, age ≥ 65 years. Results: 30‐day mortality data were available for 249 of 252 patients. CURB65 scores on admission significantly predicted risk of death during the hospital admission and at 30 days. The 30‐day mortality by score groups were: low risk (scores 0–1) 2.0% (2/98), moderate risk (score 2) 6.7% (6/90) and high risk (scores 3–5) 21.3% (13/61). CURB65 scores were not predictive of 1‐year mortality. Conclusions: A simple 6‐point score based on confusion, blood urea, respiratory rate, blood pressure and age can be used to stratify patients with COPD exacerbation into different management groups. The CURB65 score was as effective in predicting early mortality in our cohort of acute COPD exacerbations as it was in previous cohorts with community acquired pneumonia. Our findings suggest that CURB65 scores can help clinicians to assess patients with exacerbation of COPD.     

Elevated High Sensitivity C‐Reactive Protein Increases the Risk of Microalbuminuria in Subjects With Cardiovascular Disease Risk Factors

Microalbuminuria is an early biomarker of kidney injury, the aim of this study was to investigate the impact of high sensitivity C‐reactive protein (hs‐CRP) on microalbuminuria in adults with cardiovascular disease (CVD) risk factors. A total of 5667 subjects who voluntarily attended annual health screenings in the Third Xiangya Hospital of Central South University were included in the study. Logistic regression was used to determine the validity of hs‐CRP to predict the presence of microalbuminuria. In the unadjusted regression analysis, male gender (OR 2.23), age (OR 1.71), smoking status (OR 1.48), obesity (OR 2.41), hypertension(OR 4.03), diabetes (OR 4.61), hyperuricemia (OR 1.83), and high hs‐CRP(OR 1.61) were associated with microalbuminuria. Multivariate logistic regression analysis showed that the adjusted odds ratios (OR) of diabetes, hypertension, male, abdominal obesity, and high hs‐CRP for microalbuminuria were 2.71, 2.57, 1.51, 1.28 and 1.41 in all subjects, respectively (P < 0.01). ROC analysis indicated that the cut‐off for hs‐CRP with better properties for screening of microalbuminuria was identified as ≥0.85 mg/L. The ORs of microalbuminuria were 1.97, 1.49, 1.32 and 1.71 times in male, abdominal obesity, diabetes and hypertension subjects with hs‐CRP ≥ 0.85 mg/L, respectively, compared with those without elevated hs‐CRP (P < 0.01). Elevated hs‐CRP level was associated with microalbuminuria independent of cardiovascular risk factors. In addition, elevated hs‐CRP increased the risk of developing microalbuminuria in subjects with CVD risk factors, indicating that chronic inflammation could amplify the deterioration of kidney by effect of CVD risk factors.