Assessment of neopterin and indoleamine 2,3-dioxygenase activity in patients with seasonal influenza: A pilot study.

BACKGROUND: Seasonal influenza is an important cause of morbidity and mortality worldwide. Immune activation after stimulation with interferon-gamma leads to increased production of neopterin but also results in increased tryptophan catabolism through indoleamine 2,3-dioxygenase (IDO). Our pilot study determined neopterin serum levels and IDO activity in patients with influenza infection and investigated whether neopterin is linked to clinical outcome parameters (mortality ≤30 days, acute cardiac events (ACE) length of hospitalization, ICU admission). METHODS: Neopterin concentrations were analyzed in serum samples of 40 patients with a confirmed diagnosis of influenza infection and in-hospital treatment for >24 hours. Data were compared to values of 100 healthy blood donors and 48 age-matched pneumonia patients. In a subgroup of 14 patients, tryptophan and kynurenine concentrations, as well as kynurenine-to-tryptophan ratio, were analyzed. RESULTS: In all influenza patients, neopterin concentrations were increased and significantly higher compared to those determined in patients with pneumonia and healthy controls. Positive correlations between the duration of hospitalization and neopterin were found. Significantly higher levels of kynurenine, kynurenine-to-tryptophan ratio, and lower levels of tryptophan were seen in influenza patients compared to healthy controls. CONCLUSIONS: Neopterin seems to be related to the course of the disease and could be a valuable biomarker to identify patients at an elevated risk of a worsened outcome; however, further prospective validation studies are needed to support the here presented preliminary results.

Advanced Lung Cancer Inflammation Index Predicts Outcomes of Patients with Pathological Stage IA Lung Adenocarcinoma Following Surgical Resection.

PURPOSE: The correlation of advanced cancer with inflammation and/or nutrition factors is well known. Recently, the advanced lung cancer inflammation index (ALI) was developed as a new prognostic tool for patients with advanced lung cancer. In this study, we examined whether ALI results are correlated with prognosis of patients with early stage lung adenocarcinoma who undergo lung resection. METHODS: From January 2009 to December 2014, 544 patients underwent lung resection due to primary lung cancer at Dokkyo Medical University Hospital, of whom 166 with pathological stage IA lung adenocarcinoma were retrospectively investigated in this study. ALI was calculated as follows: Body Mass Index (BMI; kg/m2) × albumin (g/dL)/neutrophil-to-lymphocyte ratio (NLR). RESULTS: Multivariate analysis revealed that gender, red cell distribution width (RDW), NLR, and ALI were parameters significantly correlated with overall survival (OS). Patients with an ALI value less than 22.2 had an inferior 5-year OS rate as compared to those with a value of 22.2 or higher (p <0.001) as well as an inferior 5-year recurrence-free survival (RFS) rate (p <0.001). CONCLUSION: Low ALI was correlated with poor prognosis in patients with stage IA lung adenocarcinoma. Those with an ALI value less than 22.2 should be carefully followed regardless of cancer stage.

Usability Testing of a Reusable Pulse Oximeter Probe Developed for Health-Care Workers Caring for Children < 5 Years Old in Low-Resource Settings.

Hypoxemia measured by pulse oximetry predicts child pneumonia mortality in low-resource settings (LRS). Existing pediatric oximeter probes are prohibitively expensive and/or difficult to use, limiting LRS implementation. Using a human-centered design, we developed a low-cost, reusable pediatric oximeter probe for LRS health-care workers (HCWs). Here, we report probe usability testing. Fifty-one HCWs from Malawi, Bangladesh, and the United Kingdom participated, and seven experts provided reference measurements. Health-care workers and experts measured the peripheral arterial oxyhemoglobin saturation (SpO2) independently in < 5 year olds. Health-care worker measurements were classed as successful if recorded in 5 minutes (or shorter) and physiologically appropriate for the child, using expert measurements as the reference. All expert measurements were considered successful if obtained in < 5 minutes. We analyzed the proportion of successful SpO2 measurements obtained in < 1, < 2, and < 5 minutes and used multivariable logistic regression to predict < 1 minute successful measurements. We conducted four testing rounds with probe modifications between rounds, and obtained 1,307 SpO2 readings. Overall, 67% (876) of measurements were successful and achieved in < 1 minute, 81% (1,059) < 2 minutes, and 90% (1,181) < 5 minutes. Compared with neonates, increasing age (infant adjusted odds ratio [aOR]; 1.87, 95% confidence interval [CI]: 1.16, 3.02; toddler aOR: 4.33, 95% CI: 2.36, 7.97; child aOR; 3.90, 95% CI: 1.73, 8.81) and being asleep versus being calm (aOR; 3.53, 95% CI: 1.89, 6.58), were associated with < 1 minute successful measurements. In conclusion, we designed a novel, reusable pediatric oximetry probe that was effectively used by LRS HCWs on children. This probe may be suitable for LRS implementation.

The role of presepsin in the diagnosis and assessment of severity of sepsis and severe pneumonia.

AIM: The aim of this study was to evaluate marker of inflammation presepsin to improve diagnosis of severe pneumonia, sepsis. MATERIALS AND METHODS: 75 patients with pneumonia, sepsis, other inflammatory diseases aged from 17 to 78 years were examined. These patients have been investigated for the level of the presepsin. Presepsin level was quantified on immunohemilyuministsentny analyzer Pathfast (Mitsubishi Chemical Medience Corporation, Japan) in pg/ml. All patients had obtained an antibacterial therapy in other health care organizations before entering the hospital. RESULTS: Рresepsin at the general group of patients with pneumogenic sepsis was 3196.9±1202.16 pg/mL (n=14, x̅±m), with abdominal sepsis - 2506.7±448.32 pg/mL (n=28), with other inflammatory diseases - 671.6±124.55 pg/mL (n=11). Рresepsin of patients with pneumogenic sepsis was 1125.3±240.59 pg/mL (n=3), presepsin of patients with severe pneumonia was - 362.6±76.29 pg/mL (n=13, р<0.05), non-severe pneumonia - 157.3±33.02 pg/mL (n=9, р<0.05). CONCLUSION: The high level of presepsin is an indication of an active infectious disease and reflects the severity of the pneumonia and development of sepsis. Keeping a high level against the backdrop of earlier presepsin ongoing antibiotic therapy is an indication of their lack of effectiveness. A significant variability of presepsin should be taken into account.

Association of hypercapnia on admission with increased length of hospital stay and severity in patients admitted with community-acquired pneumonia: a prospective observational study from Pakistan.

OBJECTIVE: To determine whether the presence of hypercapnia on admission in adult patients admitted to a university-based hospital in Karachi, Pakistan with community-acquired pneumonia (CAP) correlates with an increased length of hospital stay and severity compared with no hypercapnia on admission. STUDY DESIGN: A prospective observational study. SETTINGS: Tertiary care hospital in Karachi, Pakistan. METHODS: Patients who met the inclusion criteria were enrolled in the study. The severity of pneumonia was assessed by CURB-65 and PSI scores. An arterial blood gas analysis was obtained within 24 hours of admission. Based on arterial PaCO2 levels, patients were divided into three groups: hypocapnic (PaCO2 <35 mm Hg), hypercapnic (PaCO2 >45 mm Hg) and normocapnic (PaCO2 <35-45 mm Hg). OUTCOMES: The primary outcome was the association of hypercapnia on admission with mean length of hospital stay. Secondary outcomes were the need for mechanical ventilation, ICU admission and in-hospital mortality. RESULTS: A total of 295 patients of mean age 60.20±17.0 years (157 (53.22%) men) were enrolled over a 1-year period. Hypocapnia was found in 181 (61.35%) and hypercapnia in 57 (19.32%) patients. Hypercapnic patients had a longer hospital stay (mean 9.27±7.57 days), increased requirement for non-invasive mechanical ventilation (NIMV) on admission (n=45 (78.94%)) and longer mean time to clinical stability (4.39±2.0 days) compared with the other groups. Overall mortality was 41 (13.89%), but there was no statistically significant difference in mortality (p=0.35) and ICU admission (p=0.37) between the three groups. On multivariable analysis, increased length of hospital stay was associated with NIMV use, ICU admission, hypercapnia and normocapnia. CONCLUSION: Hypercapnia on admission is associated with severity of CAP, longer time to clinical stability, increased length of hospital stay and need for NIMV. It should be considered as an important criterion to label the severity of the illness and also a determinant of patients who will require a higher level of hospital care. However, further validation is required.

Assessment of the Usefulness of Multiplex Real-Time PCR Tests in the Diagnostic and Therapeutic Process of Pneumonia in Hospitalized Children: A Single-Center Experience.

The aim of the study was assessment of the usefulness of multiplex real-time PCR tests in the diagnostic and therapeutic process in children hospitalized due to pneumonia and burdened with comorbidities. Methods. The study group included 97 children hospitalized due to pneumonia at the Karol Jonscher Teaching Hospital in Poznan, in whom multiplex real-time PCR tests (FTD respiratory pathogens 33; fast-track diagnostics) were used. Results. Positive test results of the test were achieved in 74 patients (76.3%). The average age in the group was 56 months. Viruses were detected in 61 samples (82% of all positive results); bacterial factors were found in 29 samples (39% of all positive results). The presence of comorbidities was established in 90 children (92.78%). On the basis of the obtained results, 5 groups of patients were established: viral etiology of infection, 34 patients; bacterial etiology, 7 patients; mixed etiology, 23 patients; pneumocystis, 9 patients; and no etiology diagnosed, 24 patients. Conclusions. Our analysis demonstrated that the participation of viruses in causing severe lung infections is significant in children with comorbidities. Multiplex real-time PCR tests proved to be more useful in establishing the etiology of pneumonia in hospitalized children than the traditional microbiological examinations.

Assessment of Cytokine and Chemokine Signatures as Potential Biomarkers of Childhood Community-acquired Pneumonia Severity: A Nested Cohort Study in India.

BACKGROUND: Pediatric community-acquired pneumonia (CAP) is a leading cause of childhood mortality in developing countries. In resource-poor settings, pneumonia diagnosis is commonly made clinically, based on World Health Organization guidelines, where breathing difficulty or cough and age-adjusted tachypnea suffice to establish diagnosis. Also, the severity of CAP is generally based on clinical features and existing biomarkers do not reliably correlate to either clinical severity or outcome. Here, we asked whether systemic immune and inflammatory mediators could act as biomarkers predicting CAP severity or outcome. METHODS: Serum from a subset of a CAP cohort (n = 196), enrolled in India, classified according to World Health Organization criteria as having pneumonia or severe pneumonia, was used for simultaneous measurement of 21 systemic cytokines and chemokines. RESULTS: We found significantly higher IL-6, IL-8, IL-13, IFN-γ and lower CCL22 concentrations in patients with severe compared with mild CAP (P values: 0.019, 0.036, 0.006, 0.016 and 0.003, respectively). Based on higher MIP-1α, IL-8, IL-17 or lower CCL22 response pattern at the time of enrolment, children with fatal outcome showed markedly different pattern of inflammatory response compared with children classified with the same disease severity, but with nonfatal outcome (P values: 0.043, 0.017, 0.008 and 0.020, respectively). CONCLUSIONS: Our results suggest a relation between an elevated mixed cytokine response and CAP severity on one hand, and a bias toward uncontrolled neutrophilic inflammation in subjects with fatal outcome on the other. Collectively our findings contribute to increased knowledge on new biomarkers that can potentially predict severity and outcome of childhood CAP in the future.

Severity Assessment and the Immediate and Long-Term Prognosis in Community-Acquired Pneumonia.

Severity assessment is a crucial step in the initial management of patients with community-acquired pneumonia (CAP). While approximately half of patients are at low risk of death and can be safely treated as outpatients, around 20% are at increased risk. While CURB-65 (confusion, respiratory rate, blood pressure, urea) and pneumonia severity index (PSI) scores are equally useful as an adjunct to clinical judgment to identify patients at low risk, the so-called minor American Thoracic Society/Infectious Diseases Society of America criteria are predictive of patients in need of intensified treatment (i.e., mechanical ventilation and/or vasopressor treatment). Such patients represent medical emergencies. In elderly patients, CRB-65 (confusion, respiratory rate, blood pressure, age) is no longer predictive of low risk; instead, poor functional status is the best predictor of death. In addition to scores, assessment of oxygenation and unstable comorbidity, as well as lactate and biomarkers remain important to consider. The added value of combined clinical and biomarker risk stratification strategies should be evaluated in large prospective interventional trials.Survivors of hospitalized CAP have a considerable excess long-term mortality. Risk factors include age, male gender, and nursing home residency, as well as increased PSI and CURB-65 scores. Cardiovascular, pulmonary, renal, and neoplastic comorbidities are prominent causes of long-term mortality. Comorbidities are vulnerable to both the acute and chronic subclinical inflammatory challenge delivered by pulmonary infection and are thereby drivers of mortality. Biomarkers are promising in identifying patients at increased risk of long-term mortality. Future studies should develop consistent strategies of risk stratification and intervention to improve long-term outcomes of patients with CAP.

Valuable hematological indicators for the diagnosis and severity assessment of Chinese children with community-acquired pneumonia: Prealbumin.

Chest X-ray is a "golden standard" for the diagnosis and severity assessment of community-acquired pneumonia (CAP). However, it cannot be used as routine examination of CAP in children. The present study aims to investigate the roles of prealbumin (PA) in CAP in children and further determine the usefulness of PA in diagnosis and severity assessment of CAP in children.This was a retrospective analysis of 174 cases of hospitalized children with CAP. The following indicators were recorded: vital sign, inflammatory indexes, PA, and respiratory pathogens immunoglobulin M antibody test results. A total of 33 healthy children were selected as the control group. The results of laboratory tests between CAP and control groups were compared. CAP group was further divided into mild CAP and severe CAP groups, and vital signs and laboratory examination results of 2 groups were compared.The total positive rate of Mycoplasma pneumoniae in this study was 27.4%, and there was no significant difference in different seasons (P = 0.356). Compared with controls, there was no significant difference between procalcitonin and C-reactive protein in CAP group (P = 0.355, 0.061). The white blood cell count, percentage of neutrophils, neutrophil count, and erythrocyte sedimentation rate in the CAP group were significantly higher than those in control group, and PA was significantly lower than that in the control group (all P < 0.05). In the traditional cutoff value (<170 mg/L), the sensitivity of PA for the diagnosis of CAP was 0.847, which was significant higher than traditional inflammatory indicators. Moreover, it was found that PA was an independent protective factor for CAP in children based on multivariate analysis (odds ratio: 0.974; 95% confidence interval: 0.956-0.993; P = 0.008). PA level in severe CAP group was significantly lower than in mild CAP group (P = 0.001). With a cutoff value of 125 mg/L, the sensitivity and specificity of PA for the severity assessment of CAP were 0.703 and 0.714, respectively.Combined with traditional inflammatory markers, PA may improve the diagnostic efficacy of CAP in children. PA can be used as a reference marker to complement the chest X-rays for severity assessment of children CAP.

A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia.

OBJECTIVE: To determine the clinical utility and cost-effectiveness of universal vs targeted approach to obtaining blood cultures in children hospitalized with community-acquired pneumonia (CAP). STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision tree to compare 2 approaches to ordering blood cultures in children hospitalized with CAP: obtaining blood cultures in all children admitted with CAP (universal approach) and obtaining blood cultures in patients identified as high risk for bacteremia (targeted approach). We searched the literature to determine expected proportions of high-risk patients, positive culture rates, and predicted bacteria and susceptibility patterns. Our primary clinical outcome was projected rate of missed bacteremia with associated treatment failure in the targeted approach. Costs per 100 patients and annualized costs on the national level were calculated for each approach. RESULTS: The model predicts that in the targeted approach, there will be 0.07 cases of missed bacteremia with treatment failure per 100 patients, or 133 annually. In the universal approach, 118 blood cultures would need to be drawn to identify 1 patient with bacteremia, in which the result would lead to a meaningful antibiotic change compared with 42 cultures in the targeted approach. The universal approach would cost $5178 per 100 patients or $9,214,238 annually. The targeted approach would cost $1992 per 100 patients or $3,545,460 annually. The laboratory-related cost savings attributed to the targeted approach would be projected to be $5,668,778 annually. CONCLUSIONS: This decision analysis model suggests that a targeted approach to obtaining blood cultures in children hospitalized with CAP may be clinically effective, cost-saving, and reduce unnecessary testing.

Solar-powered oxygen delivery: study protocol for a randomized controlled trial.

BACKGROUND: Pneumonia is a leading cause of childhood mortality globally. Oxygen therapy improves survival in children with pneumonia, yet its availability remains limited in many resource-constrained settings where most deaths occur. Solar-powered oxygen delivery could be a sustainable method to improve oxygen delivery in remote areas with restricted access to a supply chain of compressed oxygen cylinders and reliable electrical power. METHODS/DESIGN: This study is a randomized controlled trial (RCT). Solar-powered oxygen delivery systems will be compared to a conventional method (oxygen from cylinders) in patients with hypoxemic respiratory illness. Enrollment will occur at two sites in Uganda: Jinja Regional Referral Hospital and Kambuga District Hospital. The primary outcome will be the length of hospital stay. Secondary study endpoints will be mortality, duration of supplemental oxygen therapy (time to wean oxygen), proportion of patients successfully oxygenated, delivery system failure, cost, system maintenance and convenience. DISCUSSION: The RCT will provide useful data on the feasibility and noninferiority of solar-powered oxygen delivery. This technological innovation uses freely available inputs, the sun and the air, to oxygenate children with pneumonia, and can be applied "off the grid" in remote and/or resource-constrained settings where most pneumonia deaths occur. If proven successful, solar-powered oxygen delivery systems could be scaled up and widely implemented for impact on global child mortality. TRIAL REGISTRATION: Clinicaltrials.gov registration number NCT0210086 (date of registration: 27 March, 2014).

Accuracy of PaO2 /FiO2 calculated from SpO2 for severity assessment in ED patients with pneumonia.

BACKGROUND AND OBJECTIVE: Assessment of oxygenation in patients with community-acquired pneumonia is critical for treatment. The accuracy of percutaneous oxygen saturation (SpO2 ) determined by pulse oximetry is uncertain, and it has limited value in patients receiving supplemental oxygen. We hypothesized that calculation of partial arterial oxygen concentration/inspired oxygen faction (PaO2 /FiO2 ) from SpO2 by the Ellis or Rice equations might adequately correlate with PaO2 /FiO2 measured by arterial blood gases. METHODS: We studied 1004 patients with pneumonia in the emergency department with simultaneous measurement of SpO2 and PaO2 from two cohorts from Valencia, Spain and Utah, USA. We compared SpO2 with measured SaO2 , compared the equations' accuracy in calculating PaO2 /FiO2 and determined how often patients would be misclassified at clinically important thresholds. We compared estimated PaO2 /FiO2 to measured PaO2 /FiO2 using the Spearman correlation. RESULTS: Pairwise correlation of SpO2 with SaO2 was moderate (rho = 0.66; P < 0.01). Both equations performed similarly among patients with lower PaO2 /FiO2 ratios. The Ellis equation estimated PaO2 /FiO2 from SpO2 more accurately than the Rice equation in patients with PaO2 /FiO2 ≥200. Simple agreement between calculated and measured P/F was 91% and 92%, respectively. CONCLUSIONS: The Ellis equation was more accurate than the Rice equation for estimating PaO2 /FiO2 , especially at higher levels of P/F ratio. Estimation of PaO2 /FiO2 from SpO2 is accurate enough for initial oxygenation assessment. Ellis and Rice equations could misclassify 20% and 30% of patients, respectively, at higher levels of PaO2 /FiO2 . For patients with abnormal oxygenation falling near thresholds for clinical decision making, arterial blood gas measurement preferably on room air is more accurate.

B-type natriuretic peptide-guided risk assessment for postoperative complications in lung cancer surgery.

BACKGROUND: Since lung cancer surgery is still associated with a high complication rate, it is important to efficiently identify patients at high risk for postoperative complications following lung cancer surgery. We previously reported that elderly patients with elevated preoperative B-type natriuretic peptide (BNP) levels (>30 pg/mL) have an increased risk for postoperative atrial fibrillation and cardiopulmonary complications following lung cancer surgery. The objective of this study was to evaluate the clinical utility of BNP-guided risk classification for postoperative complications after lung cancer surgery. METHODS: A total of 675 consecutive patients who underwent curative surgery for lung cancer in two specialized thoracic centers between 2007 and 2011 were included in this retrospective study. We evaluated the association between the incidence of postoperative complications and preoperative BNP levels. RESULTS: Univariable and multivariable stepwise logistic regression analyses revealed that an elevated preoperative BNP level was the most significant predictor of postoperative complications. All patients were classified by their preoperative BNP levels into a normal group (<30 pg/mL), a mildly elevated group (30-100 pg/mL), and a severely elevated group (>100 pg/mL). The incidence of postoperative complications was significantly higher in the severely and mildly elevated groups than in the control group (85 % and 47 % vs. 11 %, P < 0.0001). Furthermore, there were more severe complications and a higher mortality rate in the severely elevated group. CONCLUSIONS: Risk assessment using preoperative BNP levels was clinically useful for the identification of patients at high risk for postoperative complications.

Assessment of oxidative stress biomarkers in exhaled breath condensate and blood of Thoroughbred foals.

This study reports preliminary data on systemic and local biomarkers of oxidative stress (OS) in Thoroughbred foals. Blood and exhaled breath condensate (EBC) were sampled from 13 foals on two farms. Values of reactive oxygen metabolites (d-ROMs), biological antioxidant potential (BAP), antioxidant barrier (OXY-ads), thiol antioxidant barrier (SHp) and advanced oxidation protein products (AOPPs) were determined in blood, while EBC samples were assayed for hydrogen peroxide (H(2)O(2)) levels. Systemic and local OS biomarkers did not differ between farms and gender. Increased oxidative stress index (OSI) values in a foal recovering from pneumonia and elevated H(2)O(2) in EBC coupled with low SHp and elevated AOPPs in the blood of a foal with overt upper respiratory tract disease suggested that the OS markers measured in this study may relate to the respiratory health status of foals.

Endogenous carboxyhemoglobin concentrations in the assessment of severity in patients with community-acquired pneumonia.

INTRODUCTION: Previous studies have shown that carbon monoxide, which is endogenously produced, is increased in community-acquired pneumonia (CAP). However, it has not been studied enough whether severity of pneumonia is correlated with increased carboxyhemoglobin (COHb) concentrations in CAP. The aim of this study was to determine whether endogenous carbon monoxide levels in patients with CAP were higher compared with the control group and, if so, to determine whether COHb concentrations could predict severity in CAP. MATERIALS AND METHODS: Eighty-two patients with CAP were evaluated in this cross-sectional study during a 10-month period. Demographic data, pneumonia severity index and confusion, uremia, rate respiratory, pressure blood, age>65 (CURB-65) scores, hospital admission or discharge decisions, and 30-day hospital mortality rate were recorded. In addition, 83 control subjects were included to study. The COHb concentration was measured in arterial blood sample. RESULTS: The levels of COHb in patients with CAP were 1.70% (minimum-maximum, 0.8-3.2), whereas those in control subjects, 1.40% (minimum-maximum, 0.8-2.9). The higher COHb concentrations in patients with CAP were statistically significant (P < .05). Concentration of COHb correlated with pneumonia severity index (P = .04, r = 0.187); however, it did not correlate with CURB-65 (P = .218, r = 0.112). CONCLUSION: Although COHb concentrations show an increase in patients with pneumonia, it was concluded that this increase did not act as an indicator in diagnosis process or prediction of clinical severity for the physicians.

[The blood system and bone marrow during aging. The new method of hemogram assessment: blood analysis along with synthesis].

This article represents the particularities of people's blood and bone marrow referent parameters during aging. On the basis of 56 blood parameters of apparently healthy people a mathematical model of blood's morphofunctional state during physical aging was created. The following integral changes have been discovered: in age group of 35-59 years the integral indicator amounts to 0.05 +/- 0.0008, it approaches the benchmark in elderly age (0.02 +/- 0.0001) and becomes negative with people of gerontic age (-0.06 +/- 0.0003). On the basis of 14 selected blood parameters a calculation of referent integral indicators of blood state for healthy people of various age groups was performed, which serve as standards in clinical practice. Out of 70 peripheral blood cells' indicators the integral indicators for patients suffering from community-acquired pneumonia were calculated. The organism reacts to pneumonia most appropriately at the age of 22-34 years (integral indicator amounts to -0.0386). In patients of 35-59 years the integral indicator descends closer to zero mark (-0.0236), pointing to minor reaction to inflammation. Patients over 60 years of age show the biggest divergence of integral indicator from the benchmark (-0.0613), which points to an inadequate reaction of the organism to inflammation in this age. Based on discriminant analysis of 80 indicators (clinical blood analysis, cytograms, cardiac beat count, breath count, C-reactive protein) the most informatory indicators used to create the algorithm for determination of pneumonia severity were chosen.

Multidimensional assessment of older people with asthma and COPD: clinical management and health status.

BACKGROUND: the diagnosis and management of obstructive airway diseases (OADs) such as asthma and chronic obstructive pulmonary disease (COPD) can be challenging in older people. OBJECTIVE: to assess the clinical, functional, biological and behavioural characteristics relevant to the management of older people with OAD. METHODS: a cross-sectional study was conducted in a tertiary teaching hospital. Older people (> 55 years) (n = 100) with an OAD underwent a multidimensional assessment (MDA) involving questionnaires, clinical assessments, physiological measurements and biomarkers. RESULTS: the assessment identified a mean (SD) of 11.3 (2.5) clinical management issues and 3.1 (1.8) comorbid conditions per participant. Common problems were: airways hyper-responsiveness (80%); airway inflammation (74%); activity limitation (74%) and systemic inflammation (60.5%). The number and type of issues were similar irrespective of a diagnosis of asthma or COPD (P = 0.2). The degree of health status impairment correlated significantly with the number of clinical management issues detected (r = 0.59; P < 0.0001). CONCLUSIONS: older people with OAD experience multiple clinical issues that adversely impact their health status. The number and type are similar irrespective of diagnosis. This MDA identifies significant clinical issues that may not be addressed in a diagnosis centred approach suggesting that a multidisciplinary approach is necessary when assessing and managing older people with OAD.

Randomized controlled trial of day care versus hospital care of severe pneumonia in Bangladesh.

OBJECTIVE: A randomized controlled trial compared day care versus hospital care management of pneumonia. METHODS: Children 2 to 59 months of age with severe pneumonia received either day care, with antibiotic treatment, feeding, and supportive care from 8:00 am to 5:00 pm, or hospital care, with similar 24-hour treatment. RESULTS: In 2006-2008, 360 children were assigned randomly to receive either day care or hospital care; 189 (53%) had hypoxemia, with a mean±SD oxygen saturation of 93±4%, which increased to 99±1% after oxygen therapy. The mean±SD durations of day care and hospital care were 7.1±2.3 and 6.5±2.8 days, respectively. Successful management was possible for 156 (87.7% [95% confidence interval [CI]: 80.9%-90.9%]) of 180 children in the day care group and 173 (96.1% [95% CI: 92.2%-98.1%]) of 180 children in the hospital care group (P=.001). Twenty-three children in the day care group (12.8% [95% CI: 8.7%-18.4%] and 4 children in the hospital care group (2.2% [95% CI: 0.9%-5.6%] required referral to hospitals (P<.001). During the follow-up period, 22 children in the day care group (14.1% [95% CI: 9.5%-20.4%]) and 11 children in the hospital care group (6.4% [95% CI: 3.6%-11%]) required readmission to hospitals (P=.01). The estimated costs per child treated successfully at the clinic and the hospital were US$114 and US$178, respectively. CONCLUSION: Severe childhood pneumonia without severe malnutrition can be successfully managed at day care clinics, except for children with hypoxemia who require prolonged oxygen therapy.

What is the role of pulse oximetry in the assessment of patients with community-acquired pneumonia in primary care?

INTRODUCTION: Community-acquired pneumonia (CAP) is a common presenting condition in primary care. Assessment of oxygenation status using pulse oximetry is increasingly available, but its precise role in disease severity assessment is unknown. AIMS: To inform the use of pulse oximetry in patients with CAP, including the utility of different oxygenation thresholds, patient subgroups, and interaction with existing severity scores. METHODS: A prospective cohort study of adults with CAP admitted to a UK teaching hospital trust. Oxygen saturations (SpO2) and the fraction of inspired oxygen were recorded on admission. The value of different SpO2 thresholds (< 88%, ≤ 90%, ≤ 92%, and < 95%) in predicting 30-day mortality and critical care admission was analysed. RESULTS: 467 patients had SpO2 measured on room air. Admission SpO2 ≤ 90% was observed in 28% of patients and had reasonable specificity (76%) for 30-day mortality or critical care admission, but low sensitivity (46%). Specificity was particularly good for adults <50 years of age (90%) or those with asthma (92.3%). CONCLUSION: SpO2 ≤ 90% has good specificity but low sensitivity for adverse outcomes in CAP. It complements rather than replaces clinical severity scoring.

Assessment of inflammatory markers in patients with community-acquired pneumonia--influence of antimicrobial pre-treatment: results from the German competence network CAPNETZ.

BACKGROUND: There is almost no data about the influence of antimicrobial pre-treatment (APT) on levels of inflammatory markers in community acquired pneumonia (CAP). The aim of this study was to investigate the influence of APT on inflammatory markers in CAP. METHODS: 991 hospitalized patients (64.3±17.6 years, 61% male) with CAP were enrolled. In all patients procalcitonin (PCT), C-reactive protein (CRP), and leukocyte count (WBC) were determined. Patients were followed-up for 28 days for survival. RESULTS: 232 patients (23.4%) had APT, 759 had no APT. Patients without APT had significantly higher levels of PCT and WBC but not of CRP compared to those with APT. In patients without APT, survivors compared to non-survivors had lower values of PCT (0.20 ng/mL; 0.02-169.10 vs. 0.83 ng/mL; 0.04-516.30, p<0.0001), WBC (12.4×10(9)/L; 1.3-49.9 vs. 14.9×10(9)/L; 3.7-34.5, p=0.047) and CRP (107.0mg/mL; 0.3-567.0 vs. 143.5mg/mL; 5.0-589.0, p=0.006). However, in patients with APT, the values of PCT, WBC and CRP were not significantly different in survivors and non-survivors. Cox regression analysis confirmed that PCT, CRP and WBC were predictive for 28 day mortality in patients without APT but not in those with APT. CONCLUSIONS: PCT and WBC but not CRP levels are higher in patients without APT compared to those with APT. PCT, CRP and WBC are predictive for 28 days mortality exclusively in patients without APT. Interpretation of inflammatory parameters has to take into account possible APT.