Comparison of clinical characteristics between healthcare-associated pneumonia and community-acquired pneumonia in patients admitted to secondary hospitals

BackgroundSince healthcare-associated pneumonia (HCAP) is heterogeneous, clinical characteristics and outcomes are different from region to region. There can also be differences between HCAP patients hospitalized in secondary or tertiary hospitals. This study aimed to evaluate the clinical characteristics of HCAP patients admitted into secondary community hospitals.MethodsThis was a retrospective study conducted in patients with HCAP or community-acquired pneumonia (CAP) hospitalized in two secondary hospitals between March 2009 and January 2011.ResultsOf a total of 303 patients, 96 (31.7%) had HCAP. 42 patients (43.7%) resided in a nursing home or long-term care facility, 36 (37.5%) were hospitalized in an acute care hospital for ≥ 2 days within 90 days, ten received outpatient intravenous therapy, and eight attended a hospital clinic or dialysis center. HCAP patients were older. The rates of patients with CURB-65 scores of 3 or more (22.9% vs. 9.1%; p = 0.001) and PSI class IV or more (82.2% vs. 34.7%; p < 0.001) were higher in the HCAP group. Drug-resistant pathogens were more frequently detected in the HCAP group (23.9% vs. 0.4%; p < 0.001). However, Streptococcus pneumoniae was the most common pathogen in both groups. The rates of antibiotic change, use of inappropriate antibiotics, and failure of initial antibiotic therapy in the HCAP group were significantly higher. Although the overall survival rate of the HCAP group was significantly lower (82.3% vs. 96.8%; p < 0.001), multivariate analyses failed to show that HCAP itself was a prognostic factor for mortality (p = 0.826). Only PSI class IV or more was associated with increased mortality (p = 0.005).ConclusionsHCAP should be distinguished from CAP because of the different clinical features. However, the current definition of HCAP does not appear to be a prognostic for death. In addition, the use of broad-spectrum antibiotics for HCAP should be reassessed because S. pneumoniae was most frequently identified even in HCAP patients.     

Diagnostic and prognostic value of procalcitonin in community-acquired pneumonia

IntroductionThe value of measuring procalcitonin (PCT) in patients with community-acquired pneumonia (CAP) is unclear. The aim of this study was to determine the value of PCT as a marker for microbial etiology and a predictor of outcome in CAP patients.MethodsA single-center observational study was conducted with CAP patients. On admission, their leukocyte count, serum C-reactive protein level, and serum PCT level were determined, and microbiological tests were performed. Patients were classified into 4 groups according to the A-DROP scoring system, which assesses the severity of CAP.ResultsA total of 102 patients were enrolled. The pathogen was identified in 60 patients, and 31 patients had streptococcal pneumonia. The PCT levels were significantly higher in those patients with pneumococcal pneumonia than in those patients with other bacterial pneumonias (P < 0.0001). Multivariate regression analysis revealed that high PCT levels were associated with a pneumococcal etiology [odds ratio, 1.68; 95% confidence interval (CI): 1.02–2.81; P = 0.04] after adjustment for disease severity and demographic factors. The PCT levels were correlated with the A-DROP score (r = 0.49; P < 0.0001). The area under the curve for predicting mortality was highest for the A-DROP score (0.97; 95% CI: 0.92–0.99), followed by the area under the curve for PCT (0.82; 95% CI: 0.74–0.89) and C-reactive protein (0.77; 95% CI: 0.67–0.84).ConclusionsHigh PCT levels indicate that pneumococcal pneumonia and PCT levels depend on the severity of pneumonia. PCT measurements may provide important diagnostic and prognostic information for patients with CAP.     

Confusion,Urea, Respiratory Rate and Shock Index or Adjusted Shock Index (CURSI or CURASI) criteria predict mortality in community-acquired pneumonia

BackgroundCommunity-acquired pneumonia (CAP) is common and associated with a significant mortality. Shock index, heart rate divided by systolic blood pressure, has been shown to be associated with outcome in sepsis.ObjectiveTo examine the usefulness of two new criteria CURSI (confusion, urea, respiratory rate and shock index), and CURASI where shock index is replaced by temperature adjusted shock index in mortality assessment of CAP.MethodsA prospective study was conducted in Norfolk and Suffolk, UK. We explored the usefulness of CURSI and CURASI which we derived and performed mapping exercise using a different cohort. In this study we compared these new indices with the CURB-65 criteria in correctly predicting mortality in CAP.ResultsA total of 190 patients were included (males = 53%). The age range was 18–101 years (median = 76 years). There were a total of 54 deaths during a six-week follow-up. All died within 30-days. Sixty-five (34%) had severe pneumonia by CURB-65. Using CURSI and CURASI, 71(37%) and 69(36%) had severe pneumonia, respectively. The sensitivity, specificity, positive and negative predictive values in predicting death during six-week follow-up were comparable among three indices examined. The Receiver Operating Characteristic curve values (95%CI) for the criteria were 0.67(0.60–0.75) for CURB-65, 0.67(0.59–0.74) for CURSI and 0.66(0.58–0.74) for CURASI (p > 0.05). There were strong agreements between these three indices (Kappa values ≥0.75 for all). Repeating analyses in those who were aged 65 years and over (n = 135) did not alter the results.ConclusionsBoth CURSI and CURASI are similarly useful to CURB-65 in predicting deaths associated with CAP including older patients.     

Bacteremic pneumococcal pneumonia: serotype distribution,antimicrobial susceptibility,severity scores,risk factors,and mortality in a single center in Chile

AimsBacteremic pneumococcal pneumonia (BPP) is a severe condition. To evaluate seasonal distribution, mortality, serotype frequencies, antimicrobial susceptibility, and different severity scores among patients with BPP.Patients and methodsPatients were identified by laboratory data and restricted to adulthood. Standard methods were used for serotyping and antimicrobial susceptibility. Risk factors were analyzed by univariate and multivariate methods. Severity scores (APACHE II, CURB-65 and CAP PIRO) were compared using ROC curves.ResultsSixty events of community-acquired BPP occurred between 2005 and 2010. A seasonal pattern was detected. Mean age was 72.1 years old (81.4% ≥60 years). All had a predisposing factor. Previous influenza (3.3%) or pneumococcal immunization (1.7%) was infrequent. Admission to critical units was required by 51.7%. Twenty-two serotypes were identified among 59 strains. Only one strain had intermediate resistance to penicillin (1.7%). In-hospital mortality reached 33.3%. Multivariate analysis identified a CAP PIRO score > 3 (OR 29.7; IC95 4.7–187), age ≥65 years (OR 42.1; IC95 2.2–796), and a platelet count < 100,000/μL (OR 10.9; IC95 1.2–96) as significant independent factors associated with death. ROC curve analysis did not reveal statistical differences between the three severity scores to predict death (AUC 0.77–0.90). The prognostic yield for all of them was limited (Positive Likelihood Ratio: 1.5–3.8).ConclusionsBPP had a high case-fatality rate in this group of adult patients with no association to resistant isolates, and a low immunization record. Three independent factors were related to death and the prognostic yield of different severity scores was low.     

Trends in hospitalizations for community-acquired pneumonia in Spain: 2004 to 2013

AimTo describe trends in the incidence and outcomes of community-acquired pneumonia (CAP) hospitalizations in Spain (2004–2013).MethodsWe used national hospital discharge data to select all hospital admissions for CAP as primary diagnosis. We analyzed incidence, Charlson comorbidity index (CCI), diagnostic and therapeutic procedures, pathogens, length of hospital stay (LOHS), in-hospital mortality (IHM) and readmission.ResultsWe identified 959,465 admissions for CAP. Incidence rates of CAP increased significantly over time (from 142.4 in 2004 to 163.87 cases per 100,000 inhabitants in 2013). Time trend analyses showed significant increases in the number of comorbidities and the use of CAT of thorax, red cell transfusion, non-invasive mechanical ventilation and readmissions (all p values < 0.05). S. pneumoniae was the most frequent causative agent, but its isolation decreased over time. Overall median of LOHS was 7 days and it did not change significantly during the study period. Time trend analyses also showed significant decreases in mortality during admission for CAP. Factor associated with higher IHM included: older age, higher CCI, S. aureus isolated, use of red cell transfusion or mechanical ventilation and readmission.ConclusionsThe incidence and mortality of CAP have changed in Spain from 2004 to 2013. Although there was an increased incidence of hospitalization for this disease over time, we saw a significant reduction in IHM.     

An investigation of multimorbidity measures as risk factors for pneumonia in elderly frail patients admitted to hospital

ObjectivesTo investigate the association of different chronic comorbidities, considered singularly and together in Cumulative Illness Rating Scale (CIRS) indexes, with pneumonia diagnosis in a group of elderly frail hospitalized patients.Design and methodsWith a retrospective cohort design, all clinical records of frail (Rockwood ≥ 5) nonterminal patients ≥ 65 years old acutely admitted over a 8-month span in an internal medicine ward were evaluated. Pneumonia status and its categorization (community-acquired, CAP, vs healthcare-associated, HCAP) were defined according to chest radiology findings and validated criteria. Chronic comorbidities, CIRS Comorbidity Score and CIRS Severity Index were collected for each participant through a standardized methodology. Multivariate logistic regression models were applied to assess the association of each comorbid condition or scores with pneumonia.Results1199 patients (546 M, median age 81.9, IQR 72.8–87.9 years), of whom 239 with pneumonia (180 CAP, 59 HCAP) were evaluated. CIRS Comorbidity Score was significantly associated with pneumonia, both at an age- and sex-adjusted model and at a multivariate model (OR for each unitary increase 1.03, 95% CI 1.001–1.062, p = 0.04), together with provenience from nursing home (OR 1.96, 95% CI 1.41–2.73, p < 0.001). Among single comorbidities, only COPD (OR 2.7, 95% CI 1.9–3.6, p < 0.001) and dementia (OR 2.3, 95% CI 1.7–3.3, p < 0.001) were associated with pneumonia, while stroke, cancer, cardiovascular, chronic liver and kidney disease were not.ConclusionsIn a small cohort of elderly frail hospitalized patients, measures of multimorbidity, like CIRS, are significantly associated with the risk of pneumonia. COPD and dementia are the main conditions concurring to define this risk.     

Aspiration pneumonia in old patients with dementia. Prognostic factors of mortality

BackgroundPrognostic factors of mortality in elderly patients with dementia with aspiration pneumonia (AP) are scarcely known. We determined the mortality rate and prognostic factors in old patients with dementia hospitalized due to AP.MethodsWe prospectively studied 120 consecutive patients aged ≥ 75 years with dementia admitted with AP to two tertiary university hospitals. We collected data on demographic and clinical variables and comorbidities. Oropharyngeal swallowing was assessed by the water swallow test.ResultsSixty-one (50.8%) patients were female, and mean age was 86 ± 9 years. The swallow test was performed in 68 patients, revealing aspiration in 92.6%. Patients with repeat AP (28.3%) were more-frequently taking thickeners (61.8% vs.11.6%, p < 0.0001) and were less-frequently prescribed angiotensin-converting-enzyme (ACE) inhibitors (8.8% vs. 27.9%, p < 0.001) than patients with a first episode. Hospital mortality was 33.3%; these patients had lower lymphocyte counts and higher percentage of multilobar involvement. In the multivariate model, involvement of ≥ 2 pulmonary lobes was associated with hospital mortality (OR 3.051, 95% CI 1.248 to 7.458, p < 0.01). Six-month mortality was 50.8%; these patients were older and had worse functional capacity and laboratory data indicative of malnutrition. In the multivariate model, lower albumin levels were associated with six-month mortality (OR 1.129, 95% CI 1.008 to 1.265, p < 0.03).ConclusionIn-hospital and 6-month mortality were high (one-third and one-half patients, respectively). Multilobar involvement and lower lymphocyte counts were associated with hospital mortality, and older age, greater dependence and malnutrition with six-month mortality.     

D-dimer levels in assessing severity and clinical outcome in patients with community-acquired pneumonia. A secondary analysis of a randomised clinical trial

BackgroundD-dimer levels are in several studies elevated in patients with CAP. In this study we assess the use of D-dimer levels and its association with severity assessment and clinical outcome in patients hospitalised with community-acquired pneumonia.MethodsIn a subset of randomised trial patients with community-acquired pneumonia serial D-dimer levels was analysed. CURB-65 scores were calculated at admission.ResultsA total of 147 patients were included. D-dimer levels at admission were higher in patients with severe CAP (2166 ± 1258 versus1630 ± 1197 μg/l, p = 0.03), with clinical failure at day 30 (2228 ± 1512 versus 1594 ± 1078 μg/l, p = 0.02) and with early failure (2499 ± 1817 μg/l versus 1669 ± 1121 μg/l, p = 0.01). Non-survivors had higher D-dimer levels (3025 ± 2105 versus 1680 ± 1128 μg/l, p = 0.05). None of the 16 patients with D-dimer levels < 500 μg/l died. In multivariate analysis D-dimer levels were not associated with clinical outcome. D-dimer levels have poor accuracy for predicting clinical outcome at day 30 (AUC 0.62, 95% CI 0.51–0.73) or 30 day mortality (AUC 0.71 (95% CI 0.51–0.91)). Addition of D-dimer levels to CURB-65 did not increase accuracy. No differences were observed in serial D-dimer levels between patients with clinical success or failure at day 30.ConclusionD-dimer levels are elevated in patients with CAP. Significantly higher D-dimer levels are found in patients with clinical failure and with severe CAP. D-dimer levels as single biomarker or as addition to the CURB-65 have no added value for predicting clinical outcome or mortality. D-dimer levels < 500 μg/l may identify candidates at low risk for complications.     

C-reactive protein for discriminating treatment failure from slow responding pneumonia

BackgroundThe management of patients with community-acquired pneumonia (CAP) who fail to improve constitutes a challenge for clinicians. This study investigated the usefulness of C-reactive protein (CRP) changes in discriminating true treatment failure from slow response to treatment.MethodsThis prospective multicenter observational study investigated the behavior of plasma CRP levels on days 1 and 4 in hospitalized patients with CAP. We identified non-responding patients as those who had not reached clinical stability by day 4. Among them, true treatment failure and slow response situations were defined when initial therapy had to be changed or not after day 4 by attending clinicians, respectively.ResultsBy day 4, 78 (27.4%) out of 285 patients had not reached clinical stability. Among them, 56 (71.8%) patients were cured without changes in initial therapy (mortality 0.0%), and in 22 (28.2%) patients, the initial empirical therapy needed to be changed (mortality 40.9%). By day 4, CRP levels fell in 52 (92.9%) slow responding and only in 7 (31.8%) late treatment failure patients (p < 0.001). A model developed including CRP behavior and respiratory rate at day 4 identified treatment failure patients with an area under the Receiver Operating Characteristic curve of 0.87 (CI 95%, 0.78–0.96).ConclusionChanges in CRP levels are useful to discriminate between true treatment failure and slow response to treatment and can help clinicians in management decisions when CAP patients fail to improve.     

Eventos cardiovasculares tempranos y tardíos en pacientes ingresados por neumonía adquirida en la comunidad

IntroductionCommunity-acquired pneumonia increases the risk of cardiovascular events (CVE). The objective of this study was to analyze host, severity, and etiology factors associated with the appearance of early and late events and their impact on mortality.MethodProspective multicenter cohort study in patients hospitalized for pneumonia. CVE and mortality rates were collected at admission, 30-day follow-up (early events), and one-year follow-up (late events).ResultsIn total, 202 of 1,967 (10.42%) patients presented early CVE and 122 (6.64%) late events; 16% of 1-year mortality was attributed to cardiovascular disease. The host risk factors related to cardiovascular complications were: age ≥ 65 years, smoking, and chronic heart disease. Alcohol abuse was a risk factor for early events, whereas obesity, hypertension, and chronic renal failure were related to late events. Severe sepsis and Pneumonia Severity Index (PSI) ≥ 3 were independent risk factors for early events, and only PSI ≥ 3 for late events. Streptococcus pneumoniae was the microorganism associated with most cardiovascular complications. Developing CVE was an independent factor related to early (OR 2.37) and late mortality (OR 4.05).ConclusionsAge, smoking, chronic heart disease, initial severity, and S. pneumoniae infection are risk factors for early and late events, complications that have been related with an increase of the mortality risk during and after the pneumonia episode. Awareness of these factors can help us make active and early diagnoses of CVE in hospitalized CAP patients and design future interventional studies to reduce cardiovascular risk.     

Benefits from intracoronary as compared to intravenous abciximab administration for STEMI patients undergoing primary angioplasty: a meta-analysis of 8 randomized trials

BackgroundAdjunctive abciximab administration has been demonstrated to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over IV route. Therefore, the aim of the current study was to perform a meta-analysis of randomized trials (RCTs) to assess the clinical efficacy and safety of IC vs IV abciximab administration in STEMI patients undergoing primary angioplasty.MethodsWe obtained results from all RCTs enrolling STEMI patients undergoing primary percutaneous coronary intervention (PCI). The primary endpoint was mortality, while recurrent myocardial infarction, postprocedural epicardial (TIMI 3) and myocardial (MBG 2–3) perfusion were identified as secondary endpoints. The safety endpoint was the risk of major bleeding complications.ResultsA total of 8 randomized trials were finally included in the meta-analysis, enrolling a total of 3259 patients. As compared to IV route, IC abciximab was associated with a significant improvement in myocardial perfusion (OR [95% CI] = 1.76 [1.28–2.42], p < 0.001), without significant benefits in terms of mortality (OR [95% CI] = 0.85 [0.59–1.23], p = 0.39), reinfarction (OR [95% CI] = 0.79 [0.46–1.33], p = 0.37), or major bleeding complications (OR [95% CI] = 1.19 [0.76–1.87], p = 0.44). However, we observed a significant relationship between patient's risk profile and mortality benefits from IC abciximab administration (p = 0.011).ConclusionsThe present updated meta-analysis showed that IC administration of abciximab is associated with significant benefits in myocardial perfusion, but not in clinical outcome at short-term follow-up as compared to IV abciximab administration, without any excess of major bleedings in STEMI patients undergoing primary PCI. However, a significant relationship was observed between patient's risk profile and mortality benefits from IC abciximab administration. Therefore, waiting for long-term follow-up results and additional randomized trials, IC abciximab administration cannot be routinely recommended, but may be considered in high-risk patients.     

Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement

BackgroundThe impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial.MethodsWe conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not.ResultsDuring a mean follow-up of 20.5 ± 14 months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04–1.58), p = 0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13–1.73), p = 0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64–3.52), p < 0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08–1.9), p < 0.01, I² = 81%).ConclusionPost-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.     

Time to antibiotics administration and outcome in community-acquired pneumonia: Secondary analysis of a randomized controlled trial

BackgroundThe association between early antibiotic administration and outcomes remains controversial in patients hospitalized for community-acquired pneumonia.MethodsWe performed a secondary analysis of a randomized controlled trial comparing two antibiotic treatment strategies for patients hospitalized for moderately severe CAP. The univariate and multivariate associations between time to antibiotic administration (TTA) and time to clinical stability were assessed using a Cox proportional hazard model. Secondary outcomes were death, intensive care unit admission and hospital readmission up to 90 days.Results371 patients (mean age 76 years, CURB-65 score ≥ 2 in 52%) were included. Mean TTA was 4.35 h (SD 3.48), with 58.5% of patients receiving the first antibiotic dose within 4 h.In multivariate analysis, number of symptoms and signs (HR 0.876, 95% CI 0.784–0.979, p = 0.020), age (HR 0.986, 95% CI 0.975–0.996, p = 0.007), initial heart rate (HR 0.992, 95% CI 0.986–0.999, p = 0.023), and platelets count (HR 0.998, 95% CI 0.996–0.999, p = 0.004) were associated with a reduced probability of reaching clinical stability. The association between TTA and time to clinical stability was not significant (HR 1.009, 95% CI 0.977–1.042, p = 0.574). We found no association between TTA and the risk of intensive care unit admission, death or readmission up to 90 days after the initial admission.ConclusionIn patients hospitalized for moderately severe CAP, a shorter time to antibiotic administration was not associated with a favorable outcome. These findings support the current recommendations that do not assign a specific time frame for antibiotics administration.     

C-reactive protein velocity following antibiotics in patients with chronic obstructive pulmonary disease exacerbation and community acquired pneumonia

IntroductionDistinguishing community acquired pneumonia (CAP) from chronic obstructive pulmonary disease (COPD) exacerbation is a challenging task, since fever, productive cough, dyspnea, and leukocytosis are all common features of both conditions. Moreover, chest X-ray might not be sensitive enough. It is therefore quite common for physicians to prescribe unnecessary antibiotics for COPD exacerbation, leading to resistant bacteria and other related adverse affects.AimTo study whether CRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment, could provide an efficient tool for distinguishing CAP from COPD exacerbation.MethodsThe study group included 36 COPD exacerbation and 49 CAP patients, admitted to a single Internal Medicine department during the years 2004–2006. All patients were treated with cephalosporins and macrolides upon admission.ResultsCRP levels upon admission were significantly higher among CAP patients than among COPD exacerbation patients (111.5 ± 104.4 vs. 34.9 ± 28.6 mg/l, p < 0.0001). CRP levels on the second day of hospitalization, following antibiotic administration to all patients, made a sharp incline in 36.7% of CAP patients compared to only 5.9% of COPD exacerbation patients (p = 0.005), and remained unchanged in 61.8% of COPD patients compared to 16.3% of CAP patients (p = 0.0006).ConclusionsCRP levels upon admission and the delta in CRP levels following initiation of antibacterial treatment could provide an efficient tool for distinguishing CAP from COPD exacerbation.     

Necesidad de una ecocardiografía transtorácica en pacientes con tromboembolia de pulmón de riesgo bajo: revisión sistemática y metanálisis

IntroductionIt is unclear whether low-risk patients with acute symptomatic pulmonary embolism (PE) should undergo echocardiogram.MethodsWe performed a meta-analysis of studies that enrolled patients with acute low-risk PE to assess the prognostic value of echocardiographic diagnosis of right ventricular (RV) dysfunction for the primary outcome of short-term all-cause mortality, and the secondary outcome of short-term PE-related mortality. We used a random-effects model to pool study results, a Begg rank correlation method to evaluate for publication bias, and I² testing to assess heterogeneity.ResultsThe meta-analysis included a total of 11 studies 1,868 patients with low-risk PE. Ten of the 447 (2.2%; 1.1%-4.1%) low-risk patients with echocardiographic RV dysfunction died soon after the diagnosis of PE compared with 10 of 1,421 (0.7%; 0.3-1.3%) patients without RV dysfunction. RV dysfunction was not significantly associated with short-term all-cause mortality (odds ratio 2.0; 95% confidence interval, 0.8-5.1, p = .14; I² = 8%). RV dysfunction was significantly associated with short-term PE-related mortality (odds ratio 5.2; 95% confidence interval, 1.7-16, p < .01; I² = 0%).ConclusionsIn patients with low-risk PE, echocardiographic RV dysfunction is not associated with all-cause mortality, but identifies patients with an increased risk for short-term PE-related mortality.     

Percutaneous angioplasty versus atherectomy for treatment of symptomatic infra-popliteal arterial disease

BackgroundOutcomes for debulking by atherectomy (ATH) for adjunctive treatment of below the knee (BTK) symptomatic arterial disease compared to percutaneous transluminal angioplasty alone (PTA) are unclear.MethodsMEDLINE, EMBASE, PubMed and the Cochrane Central Register of Controlled Trials were queried from between 2000 and 2017 including studies comparing PTA alone to PTA-ATH. Random effect meta-analysis model was used to pool the data across the studies. Study endpoints included: vessel dissection, residual stenosis (< 30%), mortality at 12 months and amputation rates at 1 and 12 months.ResultsA total of 2587 patients (72.9 years; 63% male) were included from 4 studies (2 prospective, one of which was randomized, and 2 retrospective) comparing PTA alone to ATH-PTA in patients with symptomatic infra-popliteal disease. There was no significant difference between the two approaches in terms of vessel dissection [OR 3.73 with 95% CI 0.83 to 16.64, p = 0.08] or residual stenosis [OR 0.41 with 95% CI 0.11 to 1.60, p = 0.18]. Clinical outcomes did not differ in terms of 12 month mortality [OR 3.47 with 95% CI 0.15 to 81.37, p = 0.44], or limb amputation at 1 month [OR 1.23 with 95% CI 0.91 to 1.67, p = 0.18] or 12 months [OR: 1.02 with 95% CI 0.83 to 1.26, p = 0.83].ConclusionIn patients undergoing (BTK) intervention, PTA alone and ATH-PTA was associated with similar outcomes in terms of vessel dissection and residual stenosis, mortality at 12 months, and limb amputation at 1 or 12 months.     

Severity of acute intracerebral haemorrhage,elderly age and atrial fibrillation: Independent predictors of poor outcome at three months

Background and purposePrognostic risk factors of haemorrhagic stroke are not yet fully identified. This study investigated clinical factors leading to poor outcome at three months in patients with intracerebral haemorrhage (ICH) in order to better understand the role of clinical features in prognostic evaluation.Subjects and methodsThis was a prospective cohort study on patients having ICH admitted to two Italian hospitals (the Stroke Units at “Ospedale Santa Maria della Misericordia“, Perugia and “Ospedale C. Poma“, Mantua) between January 1, 2006 and June 30, 2010.ResultsA total of 470 consecutive ICH patients (mean age 73.89 ± 13.02 years) were included and of these, 241 (51.1%) were males. At three months, 293 (62.3%) patients had poor outcome including 133 (27.6%) deaths. The resulting significant predictors of poor outcome from univariate analysis included: age, NIH Stroke Scale Score (NIHSSS) at admission, hyperglycaemia and the presence of atrial fibrillation (AF). These variables were confirmed in logistic regression analyses as being independent predictors of disability: age (OR 1.04 95% CI, 1.02–1.07, p = 0.0001), AF (OR 3.18 95% CI, 1.12–9.05 p = 0.03) and NIHSSS (OR 1.38 95% CI, 1.28–1.48, p = 0.0001), while elderly age (OR 1.10 95% CI, 1.06–1.14, p ≤ 0.0001) and high NIHSSS (OR 1.25 95% CI, 1.19–1.31, p ≤ 0.0001) resulted being independent predictors of mortality.ConclusionsThis study found that severity of ICH, elderly age and AF were independent predictors of poor outcome in ICH patients at three months. Thereby, this highlights the importance of understanding the roles of clinical features in ICH prognostic evaluation.     

Admission Chest Radiograph Lacks Sensitivity in the Diagnosis of Community-Acquired Pneumonia

IntroductionThe clinical and epidemiological significance of community-acquired pneumonia (CAP) with a chest radiograph demonstrating no parenchymal infiltrate has not been studied. We determined the percentage of patients with a clinical diagnosis of CAP who did not have radiographic opacifications and compared this group with patients with CAP and radiographic infiltrates.MethodsPatients admitted with a diagnosis of CAP were identified. Clinical history, physical examination, laboratory studies, and microbiological cultures were reviewed in a random sample of 105 patients. Admission and subsequent chest radiographs were interpreted without knowledge of the clinical data.ResultsTwenty-one percent (22/105) of patients with a clinical diagnosis of CAP had negative chest radiographs at presentation. Demographic, clinical, and laboratory data were the same in both groups. Fifty-five percent of patients with initially negative chest radiographs who had follow-up studies developed an infiltrate within 48 hours.ConclusionsIn patients admitted with a clinical diagnosis of CAP, the initial chest radiograph lacks sensitivity and may not demonstrate parenchymal opacifications in 21% of patients. Moreover, greater than half of patients admitted with a negative chest radiograph will develop radiographic infiltrates within 48 hours. Further studies are needed to develop evidence-based criteria for the diagnosis of CAP.     

Time trends in incidence and outcomes of hospitalizations for aspiration pneumonia among elderly people in Spain (2003 − 2013)

BackgroundAspiration pneumonia (AP) is an infectious process causing high rates of mortality. The purpose of this study was: 1, to describe the incidence from 2003 to 2013 of AP hospitalizations; 2, to assess time trends in hospital outcomes variables, and; 3, to identify the factors independently associated with in-hospital mortality (IHM).MethodsA retrospective observational study using the Spanish National Hospital Database, with patients discharged between January 2003 and December 2013 was conducted. Inclusion criteria were: Subjects aged 75 years or older whose medical diagnosis included AP events code according to the ICD-9-CM: 507.x in the primary diagnosis field. Patient variables, up to 14 discharge diagnoses per patient, and up to 20 procedures performed during the hospital stay (ICD-9-CM), Charlson Comorbidity Index, readmission, length of hospital stay (LOHS), and IHM were analyzed.ResultsWe included 111,319 admissions (53.13% women). LOHS decreased in both sexes (P < 0.001) and was significantly higher in men (10.4 ± 10.31 vs. 9.56 ± 10.02 days). Readmissions increased significantly in women during the study (13.94% in 2003 to 16.41% in 2013, P < 0.001). In both sex, IHM was significantly higher in > 94 years old subjects (OR: 1.43, 95%CI 1.36–1.51) and in those with readmissions (OR: 1.20, 95%CI 1.15–1.23). For the entire population, time trend analyses showed a significant decrease in mortality from 2003 to 2013 (OR: 0.96, 95%CI 0.95–0.97).ConclusionsPatients with AP are older, male, and have more comorbidities than those without AP. Over time, LOHS and IHM decreased in both sexes, but readmissions increased significantly in women.     

Adenosine improves post-procedural coronary flow but not clinical outcomes in patients with acute coronary syndrome: a meta-analysis of randomized trials

AimsAdjunctive therapy with adenosine has been shown to improve coronary flow in patients with acute coronary syndromes (ACS); it is unclear, however, whether adenosine can effectively reduce adverse clinical events. The aim of our study was to perform a meta-analysis of all randomized controlled trials (RCTs) investigating angiographic and clinical outcomes in ACS patients undergoing PCI or thrombolysis and receiving adjunctive adenosine therapy vs. placebo.MethodsMedline/CENTRAL/EMBASE and Google Scholar database were scanned. The meta-analysis included ten RCTs (N = 3821). All-cause mortality was chosen as primary endpoint. Secondary endpoints were re-infarction (MI), heart failure (HF) symptoms (NYHA class III/IV), no-reflow (defined as TIMI 0 flow) and >50% ST-resolution.ResultsAdenosine compared to placebo was associated with a significant reduction of post-procedural no-reflow (OR [95% CI] = 0.25 [0.08–0.73], p = 0.01); however, at a median follow-up of 6 months, prior treatment with adenosine did not confer significant benefits in terms of reduction of mortality (OR_Fixed [95% CI] = 0.87 [0.69–1.09], p = 0.23), as well as re-MI (p = 0.80), HF symptoms (p = 0.44) and ST-resolution (p = 0.09). Separate analyses conducted in the subgroups of ST-elevation MI patients treated with either PCI or thrombolysis confirmed the findings found in the overall population.ConclusionsThis meta-analysis shows that adenosine adjunctive therapy does not improve survival nor reduce the rates of re-MI and HF symptoms in patients with ACS treated with PCI or thrombolysis. The beneficial effect on post-procedural coronary flow was not associated with consistent advantages on clinical outcomes.