[Diagnosis of asthma: new developments in general internal medicine]. / Diagnostic de l'asthme : nouveautés pour la médecine interne générale.

Asthma, a chronic inflammatory lung disease affecting about 10 % of the population, involves both the general internist and the pulmonologist. The risk of over and underdiagnosis generates significant health costs and evitable clinical consequences. Improved screening through dedicated anamneses and questionnaires, as well as use of fractional exhaled nitric oxide (FeNO) may improve the diagnosis of asthma in general internal medicine.

L'asthme, maladie pulmonaire inflammatoire chronique affectant environ 10 % de la population, implique autant la médecine interne générale (MIG) que la pneumologie. Les risques de sous- et surdiagnostic engendrent d'importants coûts et conséquences cliniques évitables. Améliorer le dépistage lors de l'anamnèse avec l'utilisation de questionnaires dédiés et lors des examens fonctionnels par l'utilisation de la mesure de la fraction exhalée de l'oxyde nitrique pourrait être la clé d'un meilleur diagnostic de l'asthme en MIG.

Accuracy of a score predicting the presence of an atypical pathogen in hospitalized patients with moderately severe community-acquired pneumonia.

BACKGROUND: Atypical pathogens (AP), present in some patients with community-acquired pneumonia (CAP), are intrinsically resistant to betalactam drugs, the mainstay of empirical antibiotic treatment. Adding antibiotic coverage for AP increases the risk of adverse effects and antimicrobial selection pressure, while withholding such coverage may worsen the prognosis if an AP is causative. A clinical model predicting the presence of AP would allow targeting atypical coverage for patients most likely to benefit. METHODS: This is a secondary analysis of a multicentric randomized controlled trial that included 580 adults patients hospitalized for CAP. A predictive score was built using independent predictive factors for AP identified through multivariate analysis. Accuracy of the score was assessed using area under the receiver operating curve (AUROC), sensitivity, and specificity. RESULTS: Prevalence of AP was 5.3%. Age < 75 years (OR 2.7, 95% CI 1.2-6.2), heart failure (OR 2.6, 95% CI 1.1-6.1), absence of chest pain (OR 3.0, 95% CI 1.1-8.2), natremia < 135 mmol/L (OR 3.0, 95% CI 1.4-6.6) and contracting the disease in autumn (OR 2.7, 95% CI 1.3-5.9) were independently associated with AP. A predictive score using these factors had an AUROC of 0.78 (95% CI 0.71-0.85). A score of 0 or 1 (present in 33% of patients) had 100% sensitivity and 35% specificity. CONCLUSION: Use of a score built on easily obtained clinical and laboratory data would allow safe withholding of atypical antibiotic coverage in a significant number of patients, with an expected positive impact on bacterial resistance and drug adverse effects. TRIAL REGISTRATION: NCT00818610.

[Chronic meningitis: etiologies and diagnostic work-up]. / Méningite chronique : étiologies et approche diagnostique.

We describe the case of a 62-year-old woman who presented with insidious onset and slowly progressive neurological complaints. This case illustrates the diagnostic challenges clinicians face because the lack of specific symptomatology and numerous complementary exams. The broad differential diagnosis of this disease requires a diagnostic strategy to be developed. Clinical reasoning is based on clinical, biological and radiological information and highlights the importance of an interdisciplinary approach to patient care.

Nous décrivons le cas clinique d'une patiente de 62 ans se présentant avec des symptômes neurologiques d'apparition progressive et lentement évolutifs. Ce cas illustre un défi diagnostique étant donné l'absence de spécificité des symptômes et des divers examens complémentaires à disposition. Le large diagnostic différentiel de cette affection requiert une stratégie diagnostique élaborée. Le raisonnement clinique se fonde sur des informations cliniques, biologiques et radiologiques et nécessite une approche multidisciplinaire pour finalement accéder au diagnostic.

[Diagnostic and therapeutic management of medium and long-term sequelae of SARS-CoV-2 infection]. / Prise en charge diagnostique et thérapeutique des séquelles à moyen et long termes liées à l'infection à SARS-CoV-2.

Somatic or psychological sequelae after a SARS-CoV-2 infection are common. Specific organ damage should be investigated to explain persistent symptomatology and propose a treatment. A specialized consultation for the follow-up of patients after a SARS-CoV-2 infection is useful to clinically assess the patient, organized further investigations, offer treatment options and refer the patient to other specialists or to a rehabilitation program. Such a consultation is also intended to reduce the public health burden of long Covid and to collect data that can improve our management in the future.

Les séquelles somatiques ou psychologiques après une infection à SARS-CoV-2 sont fréquentes. Des atteintes d'organes spécifiques doivent être recherchées pour expliquer une symptomatologie persistante et proposer un traitement. Une consultation spécialisée pour le suivi des patients après une infection à SARS-CoV-2 est utile pour évaluer cliniquement le patient, organiser les examens complémentaires, offrir des options de traitements et orienter le patient vers d'autres spécialistes ou un programme de réhabilitation. Une telle consultation a également pour objectif de diminuer le fardeau du Covid long sur la santé publique et de collecter les données qui pourront améliorer notre prise en charge dans le futur.

Prognosis of patients eligible for dapagliflozin in acute heart failure.

BACKGROUND: Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, was shown in the DAPA-HF study to reduce the risk of worsening heart failure or death in symptomatic patients with left ejection fraction <40%, irrespective of diabetes. The aim of this study was to evaluate eligibility status for dapagliflozin in non-selected patients hospitalized for acute decompensated heart failure (ADHF), as well as prognostic implications of this status. MATERIALS AND METHODS: Analysis of 815 patients recruited in a prospective cohort of acute heart failure at the University Hospitals of Geneva, consisting of consecutive patients admitted with ADHF. Eligibility for dapagliflozin was determined using criteria described DAPA-HF. RESULTS: Of 815 patients, 220 (27%) were eligible for dapagliflozin treatment. In survival analysis, patients who were eligible for dapagliflozin had better clinical outcomes with respect to all-cause mortality and rehospitalization as compared to those who were not eligible. In multivariate analysis, the hazard ratio for all-cause mortality or readmission in patients eligible for dapagliflozin was 0.82 (95% CI 0.68-0.999, P = .049) as compared to the non-eligible. CONCLUSIONS: Using DAPA-HF criteria, only 27% of non-selected patients admitted for ADHF are theoretically eligible for dapagliflozin. This eligibility for dapagliflozin is associated with better outcomes. Further evaluation of the benefits of dapagliflozin in selected HF patients may be of interest. This may have implications for selection criteria in future randomized effectiveness studies.

Computed tomography scan contribution to the diagnosis of community-acquired pneumonia.

PURPOSE OF REVIEW: Pneumonia is a frequent disease mainly affecting older and multimorbid patients. Symptoms and signs lack sensitivity and specificity, and chest X-ray has poor accuracy. Hence, an initial diagnosis of pneumonia has limited predictive value for the presence of pneumonia. Overdiagnosis of pneumonia leads to inappropriate antibiotic use and may delay the appropriate management of mimicking diseases. Alternative imaging strategies including computed tomography (CT)-scan or lung ultrasonography may improve the diagnosis of pneumonia. We review the recent evidence and perspectives regarding their contribution to the diagnosis and management of patients with suspected pneumonia. RECENT FINDINGS: Two studies assessed the diagnostic accuracy of CT-scan in emergency department or hospitalized patients suspected of pneumonia. CT-scan led to a net reclassification improvement of 8 and 18% of patients, and was particularly helpful to rule out the diagnosis, allowing a lowering of the number of inappropriate antibiotic prescriptions. SUMMARY: CT-scan reduces overdiagnosis of pneumonia and allows a better identification of alternative diagnoses. The impact on clinical outcomes of a strategy incorporating CT-scan for patients suspected of pneumonia should be evaluated, along with its cost-effectiveness.

Biomarkers for acute kidney injury in decompensated cirrhosis: A prospective study.

AIM: Acute kidney injury (AKI) is a frequent complication in cirrhotic patients. As serum creatinine is a poor marker of renal function in this population, we aimed to study the utility of several biomarkers in this context. METHODS: A prospective study was conducted in hospitalized patients with decompensated cirrhosis. Serum creatinine (SCr), Cystatin C (CystC), NGAL and urinary NGAL, KIM-1, protein, albumin and sodium were measured on three separate occasions. Renal resistive index (RRI) was obtained. We analyzed the value of these biomarkers to determine the presence of AKI, its aetiology [prerenal, acute tubular necrosis (ATN), or hepatorenal (HRS)], its severity and a composite clinical outcome at 30 days (death, dialysis and intensive care admission). RESULTS: We included 105 patients, of which 55 had AKI. SCr, CystC, NGAL (plasma and urinary), urinary sodium and RRI at inclusion were independently associated with the presence of AKI. SCr, CystC and plasma NGAL were able to predict the subsequent development of AKI. Pre-renal state showed lower levels of SCr, NGAL (plasma and urinary) and RRI. ATN patients had high levels of NGAL (plasma and urinary) as well as urinary protein and sodium. HRS patients presented an intermediate pattern. All biomarkers paralleled the severity of AKI. SCr, CystC and plasma NGAL predicted the development of the composite clinical outcome with the same performance as the MELD score. CONCLUSIONS: In patients with decompensated cirrhosis, early measurement of renal biomarkers provides valuable information on AKI aetiology. It could also improve AKI diagnosis and prognosis.

Low-dose computed tomography for the diagnosis of pneumonia in elderly patients: a prospective, interventional cohort study.

The diagnosis of pneumonia is challenging. Our objective was to assess whether low-dose computed tomography (LDCT) modified the probability of diagnosing pneumonia in elderly patients.We prospectively included patients aged over 65 years with a suspicion of pneumonia treated with antimicrobial therapy (AT). All patients had a chest radiograph and LDCT within 72 h of inclusion. The treating clinician assessed the probability of pneumonia before and after the LDCT scan using a Likert scale. An adjudication committee retrospectively rated the probability of pneumonia and was considered as the reference for diagnosis. The main outcome was the difference in the clinician's pneumonia probability estimates before and after LDCT and the proportion of modified diagnoses which matched the reference diagnosis (the net reclassification improvement (NRI)).A total of 200 patients with a median age of 84 years were included. After LDCT, the estimated probability of pneumonia changed in 90 patients (45%), of which 60 (30%) were downgraded and 30 (15%) were upgraded. The NRI was 8% (NRI event (-6%) + NRI non-event (14%)).LDCT modified the estimated probability of pneumonia in a substantial proportion of patients. It mostly helped to exclude a diagnosis of pneumonia and hence to reduce unnecessary AT.

Differential Association of Cx37 and Cx40 Genetic Variants in Atrial Fibrillation with and without Underlying Structural Heart Disease.

Atrial fibrillation (AF) appears in the presence or absence of structural heart disease. The majority of foci causing AF are located near the ostia of pulmonary veins (PVs), where cardiomyocytes and vascular smooth muscle cells interdigitate. Connexins (Cx) form gap junction channels and participate in action potential propagation. Genetic variants in genes encoding Cx40 and Cx37 affect their expression or function and may contribute to PV arrhythmogenicity. DNA was obtained from 196 patients with drug-resistant, symptomatic AF with and without structural heart disease, who were referred for percutaneous catheter ablation. Eighty-nine controls were matched for age, gender, hypertension, and BMI. Genotyping of the Cx40 -44G > A, Cx40 +71A > G, Cx40 -26A > G, and Cx37 1019C > T polymorphisms was performed. The promoter A Cx40 polymorphisms (-44G > A and +71A > G) showed no association with non-structural or structural AF. Distribution of the Cx40 promoter B polymorphism (-26A > G) was different in structural AF when compared to controls (p = 0.03). There was no significant difference with non-structural AF (p = 0.50). The distribution of the Cx37 1019C > T polymorphism was different in non-structural AF (p = 0.03) but not in structural AF (p = 0.08) when compared to controls. Our study describes for the first time an association of drug-resistant non-structural heart disease AF with the Cx37 1019C > T gene polymorphism. We also confirmed the association of the Cx40 - 26G > A polymorphism in patients with AF and structural disease.

Outcome in acute heart failure: prognostic value of acute kidney injury and worsening renal function.

BACKGROUND: The prognostic value of worsening renal function (WRF) in acute heart failure is debated. Moreover, it is not clear if the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in this context is detrimental. METHOD AND RESULTS: In a retrospective cohort study of 646 patients hospitalized for acute heart failure, the risk of death or readmission associated with acute kidney injury (AKI) present at admission, WRF during the 1st 7 days, and up-titration of ACEI/ARB were analyzed in a Cox proportional hazards model. AKI, WRF, hemoglobin concentration, ACEI/ARB up-titration, and use of loop diuretics before admission were significantly associated with the primary outcome in univariate analysis. In a multivariate model, the association remained significant for AKI (hazard ratio [HR] 1.29, 95% confidence interval [CI] 1.13-1.47; P = .0002), WRF (HR 1.24, 95% CI 1.06-1.45; P = .0059), and ACEI/ARB up-titration (HR 0.79, 95% CI 0.64-0.97; P = .026). There was no excess mortality in patients with ACEI/ARB up-titration despite WRF. CONCLUSIONS: Both AKI and WRF are strongly associated with poor outcome in patients hospitalized for acute heart failure. ACEI/ARB up-titration seems to be protective.

Validating the accuracy of deep learning for the diagnosis of pneumonia on chest x-ray against a robust multimodal reference diagnosis: a post hoc analysis of two prospective studies.

BACKGROUND: Artificial intelligence (AI) seems promising in diagnosing pneumonia on chest x-rays (CXR), but deep learning (DL) algorithms have primarily been compared with radiologists, whose diagnosis can be not completely accurate. Therefore, we evaluated the accuracy of DL in diagnosing pneumonia on CXR using a more robust reference diagnosis. METHODS: We trained a DL convolutional neural network model to diagnose pneumonia and evaluated its accuracy in two prospective pneumonia cohorts including 430 patients, for whom the reference diagnosis was determined a posteriori by a multidisciplinary expert panel using multimodal data. The performance of the DL model was compared with that of senior radiologists and emergency physicians reviewing CXRs and that of radiologists reviewing computed tomography (CT) performed concomitantly. RESULTS: Radiologists and DL showed a similar accuracy on CXR for both cohorts (p ≥ 0.269): cohort 1, radiologist 1 75.5% (95% confidence interval 69.1-80.9), radiologist 2 71.0% (64.4-76.8), DL 71.0% (64.4-76.8); cohort 2, radiologist 70.9% (64.7-76.4), DL 72.6% (66.5-78.0). The accuracy of radiologists and DL was significantly higher (p ≤ 0.022) than that of emergency physicians (cohort 1 64.0% [57.1-70.3], cohort 2 63.0% [55.6-69.0]). Accuracy was significantly higher for CT (cohort 1 79.0% [72.8-84.1], cohort 2 89.6% [84.9-92.9]) than for CXR readers including radiologists, clinicians, and DL (all p-values < 0.001). CONCLUSIONS: When compared with a robust reference diagnosis, the performance of AI models to identify pneumonia on CXRs was inferior than previously reported but similar to that of radiologists and better than that of emergency physicians. RELEVANCE STATEMENT: The clinical relevance of AI models for pneumonia diagnosis may have been overestimated. AI models should be benchmarked against robust reference multimodal diagnosis to avoid overestimating its performance. TRIAL REGISTRATION: NCT02467192 , and NCT01574066 . KEY POINT: • We evaluated an openly-access convolutional neural network (CNN) model to diagnose pneumonia on CXRs. • CNN was validated against a strong multimodal reference diagnosis. • In our study, the CNN performance (area under the receiver operating characteristics curve 0.74) was lower than that previously reported when validated against radiologists' diagnosis (0.99 in a recent meta-analysis). • The CNN performance was significantly higher than emergency physicians' (p ≤ 0.022) and comparable to that of board-certified radiologists (p ≥ 0.269).

Revisiting the chemistry of the actinocenes [(η8-C8H8)2An] (An = U, Th) with neutral Lewis bases. Access to the bent sandwich complexes [(η8-C8H8)2An(L)] with thorium (L = py, 4,4'-bipy, tBuNC, R4phen).

In stark contrast to uranocene, (Cot)2Th reacts with neutral mono- or bidentate Lewis bases to give the bent sandwich complexes (Cot)2Th(L) (L = py, 4,4'-bipy, tBuNC, phen, Me4phen). DFT calculations in the gas phase show that, for both U and Th, formation of the bent compound (Cot)2An(L) should be facile, the linear and bent forms being close in energy.

[Threshold for allogeneic red cell transfusions in adult patients]. / Stratégie transfusionnelle pour les concentrés erythrocytaires chez l'adulte.

Red cell concentrate is a life-saving but expensive and sometimes limited resource. Its use is associated with a wide range of rare but potentially severe complications. Adequate red cell transfusion is critical in terms of costs, resource utilization and safety. Transfusion thresholds have been widely debated and recent evidence suggest that a restrictive transfusion strategy may allow safely reducing the use of red cell concentrates and even improving clinical outcomes in some situations. The aim of this article is to review the physiologic adaptive responses to anemia and to discuss the clinical evidence about erythrocyte transfusion strategies in adult patients in order to provide evidence-based transfusion recommendations.

Prediction of severe community-acquired pneumonia: a systematic review and meta-analysis.

INTRODUCTION: Severity assessment and site-of-care decisions for patients with community-acquired pneumonia (CAP) are pivotal for patients' safety and adequate allocation of resources. Late admission to the intensive care unit (ICU) has been associated with increased mortality in CAP. We aimed to review and meta-analyze systematically the performance of clinical prediction rules to identify CAP patients requiring ICU admission or intensive treatment. METHODS: We systematically searched Medline, Embase, and the Cochrane Controlled Trials registry for clinical trials evaluating the performance of prognostic rules to predict the need for ICU admission, intensive treatment, or the occurrence of early mortality in patients with CAP. RESULTS: Sufficient data were available to perform a meta-analysis on eight scores: PSI, CURB-65, CRB-65, CURB, ATS 2001, ATS/IDSA 2007, SCAP score, and SMART-COP. The estimated AUC of PSI and CURB-65 scores to predict ICU admission was 0.69. Among scores proposed for prediction of ICU admission, ATS-2001 and ATS/IDSA 2007 scores had better operative characteristics, with a sensitivity of 70% (CI, 61 to 77) and 84% (48 to 97) and a specificity of 90% (CI, 82 to 95) and 78% (46 to 93), but their clinical utility is limited by the use of major criteria. CONCLUSIONS: New severity scores for predicting the need for ICU or intensive treatment in patients with CAP, such as ATS/IDSA 2007 minor criteria, SCAP score, and SMART-COP, have better discriminative performances compared with PSI and CURB-65. High negative predictive value is the most consistent finding among the different prediction rules. These rules should be considered an aid to clinical judgment to guide ICU admission in CAP patients.

Sensitivity and predictive value of 15 PubMed search strategies to answer clinical questions rated against full systematic reviews.

BACKGROUND: Clinicians perform searches in PubMed daily, but retrieving relevant studies is challenging due to the rapid expansion of medical knowledge. Little is known about the performance of search strategies when they are applied to answer specific clinical questions. OBJECTIVE: To compare the performance of 15 PubMed search strategies in retrieving relevant clinical trials on therapeutic interventions. METHODS: We used Cochrane systematic reviews to identify relevant trials for 30 clinical questions. Search terms were extracted from the abstract using a predefined procedure based on the population, interventions, comparison, outcomes (PICO) framework and combined into queries. We tested 15 search strategies that varied in their query (PIC or PICO), use of PubMed's Clinical Queries therapeutic filters (broad or narrow), search limits, and PubMed links to related articles. We assessed sensitivity (recall) and positive predictive value (precision) of each strategy on the first 2 PubMed pages (40 articles) and on the complete search output. RESULTS: The performance of the search strategies varied widely according to the clinical question. Unfiltered searches and those using the broad filter of Clinical Queries produced large outputs and retrieved few relevant articles within the first 2 pages, resulting in a median sensitivity of only 10%-25%. In contrast, all searches using the narrow filter performed significantly better, with a median sensitivity of about 50% (all P < .001 compared with unfiltered queries) and positive predictive values of 20%-30% (P < .001 compared with unfiltered queries). This benefit was consistent for most clinical questions. Searches based on related articles retrieved about a third of the relevant studies. CONCLUSIONS: The Clinical Queries narrow filter, along with well-formulated queries based on the PICO framework, provided the greatest aid in retrieving relevant clinical trials within the 2 first PubMed pages. These results can help clinicians apply effective strategies to answer their questions at the point of care.

Atypical Pathogens in Adult Community-Acquired Pneumonia and Implications for Empiric Antibiotic Treatment: A Narrative Review.

Atypical pathogens are intracellular bacteria causing community-acquired pneumonia (CAP) in a significant minority of patients. Legionella spp., Chlamydia pneumoniae and psittaci, Mycoplasma pneumoniae, and Coxiella burnetii are commonly included in this category. M. pneumoniae is present in 5-8% of CAP, being the second most frequent pathogen after Streptococcus pneumoniae. Legionella pneumophila is found in 3-5% of inpatients. Chlamydia spp. and Coxiella burnetii are present in less than 1% of patients. Legionella longbeachae is relatively frequent in New Zealand and Australia and might also be present in other parts of the world. Uncertainty remains on the prevalence of atypical pathogens, due to limitations in diagnostic means and methodological issues in epidemiological studies. Despite differences between CAP caused by typical and atypical pathogens, the clinical presentation alone does not allow accurate discrimination. Hence, antibiotics active against atypical pathogens (macrolides, tetracyclines and fluoroquinolones) should be included in the empiric antibiotic treatment of all patients with severe CAP. For patients with milder disease, evidence is lacking and recommendations differ between guidelines. Use of clinical prediction rules to identify patients most likely to be infected with atypical pathogens, and strategies of narrowing the antibiotic spectrum according to initial microbiologic investigations, should be the focus of future investigations.

LOw-dose CT Or Lung UltraSonography versus standard of care based-strategies for the diagnosis of pneumonia in the elderly: protocol for a multicentre randomised controlled trial (OCTOPLUS).

INTRODUCTION: Pneumonia is a leading cause of mortality and a common indication for antibiotic in elderly patients. However, its diagnosis is often inaccurate. We aim to compare the diagnostic accuracy, the clinical and cost outcomes and the use of antibiotics associated with three imaging strategies in patients >65 years old with suspected pneumonia in the emergency room (ER): chest X-ray (CXR, standard of care), low-dose CT scan (LDCT) or lung ultrasonography (LUS). METHODS AND ANALYSIS: This is a multicentre randomised superiority clinical trial with three parallel arms. Patients will be allocated in the ER to a diagnostic strategy based on either CXR, LDCT or LUS. All three imaging modalities will be performed but the results of two of them will be masked during 5 days to the patients, the physicians in charge of the patients and the investigators according to random allocation. The primary objective is to compare the accuracy of LDCT versus CXR-based strategies. As secondary objectives, antibiotics prescription, clinical and cost outcomes will be compared, and the same analyses repeated to compare the LUS and CXR strategies. The reference diagnosis will be established a posteriori by a panel of experts. Based on a previous study, we expect an improvement of 16% of the accuracy of pneumonia diagnosis using LDCT instead of CXR. Under this assumption, and accounting for 10% of drop-out, the enrolment of 495 patients is needed to prove the superiority of LDCT over CRX (alpha error=0.05, beta error=0.10). ETHICS AND DISSEMINATION: Ethical approval: CER Geneva 2019-01288. TRIAL REGISTRATION NUMBER: NCT04978116.

Risks and benefits of urinary catheterisation during inpatient diuretic therapy for acute heart failure: a retrospective, non-inferiority, cohort study.

OBJECTIVES: Patients with acute congestive heart failure (HF) regularly undergo urinary catheterisation (UC) at hospital admission. We hypothesised that UC has no clinical benefits with regard to weight loss during inpatient diuretic therapy for acute congestive HF and increases the risk of urinary tract infection (UTI). DESIGN: Retrospective, non-inferiority study. SETTING: Geneva University Hospitals' Department of Medicine, a tertiary centre. PARTICIPANTS: In a cohort of HF patients, those catheterised within 24 hours of diuretic therapy (n=113) were compared with non-catheterised patients (n=346). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary endpoint was weight loss 48 hours after starting diuretic therapy. Secondary endpoints were time needed to reach target weight, discontinuation of intravenous diuretics and resolution of respiratory failure. Complications included the time to a first UTI, first hospital readmission and death. RESULTS: A total of 48-hour weight loss was not statistically different between groups and the adjusted difference was below the non-inferiority boundary of 1 kg (0.43 kg (95% CI: -0.03 to 0.88) in favour of UC, p<0.01 for non-inferiority). UC was not associated with time to reaching target weight (adjusted HR 1.0; 95% CI: 0.7 to 1.5), discontinuation of intravenous diuretics (aHR 0.9; 95% CI: 0.7 to 1.2) or resolution of respiratory failure (aHR 1.1; 95% CI: 0.5 to 2.4). UC increased the risk of UTI (aHR 2.5; 95% CI: 1.5 to 4.2) but was not associated with hospital readmission (aHR 1.1; 95% CI: 0.8 to 1.4) or 1-year mortality (aHR 1.4; 95% CI: 1.0 to 2.1). CONCLUSION: In this retrospective study, with no obvious hourly diuresis-based diuretic adjustment strategy, weight loss without UC was not inferior to weight loss after UC within 24 hours of initiating diuretic treatment. UC had no impact on clinical improvement and increased the risk of UTI. This evidence, therefore, argues against the systematic use of UC during a diuretic therapy for HF.

Kinetics of inflammatory biomarkers to predict one-year mortality in older patients hospitalized for pneumonia: a multivariable analysis.

OBJECTIVES: Long-term mortality is increased in older patients with pneumonia. We aimed to test whether residual inflammation is predictive of one-year mortality after pneumonia. METHODS: Inflammation biomarkers (C-reactive protein [CRP], interleukin [IL]-6 and IL-8, tumor necrosis factor-α, serum amyloid A, neopterin, myeloperoxidase, anti-apolipoprotein A-1, and anti-phosphorylcholine IgM) were measured at admission and discharge in older patients hospitalized for pneumonia in a prospective study. Univariate and multivariate analyses were conducted using absolute level at discharge and relative and absolute differences between admission and discharge for all biomarkers, along with usual prognostic factors. RESULTS: In the 133 included patients (median age, 83 years [interquartile range: 78-89]), one-year mortality was 26%. In univariate analysis, the relative difference of CRP levels had the highest area under the receiver operating characteristic curve (0.70; 95% confidence interval [CI] 0.60-0.80). A decrease of CRP levels of more than 67% between admission and discharge had 68% sensitivity and 68% specificity to predict survival. In multivariate analysis, lower body mass index (hazard ratio=0.87 [CI 95% 0.79-0.96], P-value=0.01), higher IL-8 (hazard ratio=1.02 [CI 95% 1.00-1.04], P-value=0.02), and higher CRP (1.01 [95% CI 1.00-1.02], P=0.01) at discharge were independently associated with mortality. CONCLUSION: Higher IL-8 and CRP levels at discharge were independently associated with one-year mortality. The relative CRP difference during hospitalization was the best individual biomarker for predicting one-year mortality.