Initial management of pneumonia and sepsis: factors associated with improved outcome.

Processes of care and adherence to guidelines have been associated with improved survival in community-acquired pneumonia (CAP). In sepsis, bundles of processes of care have also increased survival. We aimed to audit compliance with guideline-recommended processes of care and its impact on outcome in hospitalised CAP patients with sepsis. We prospectively studied 4,137 patients hospitalised with CAP in 13 hospitals. The processes of care evaluated were adherence to antibiotic prescription guidelines, first dose within 6 h and oxygen assessment. Outcome measures were mortality and length of stay (LOS). Oxygen assessment was measured in 3,745 (90.5%) patients; 3,024 (73.1%) patients received antibiotics according to guidelines and 3,053 (73.8%) received antibiotics within 6 h. In CAP patients with sepsis, the strongest independent factor for survival was antibiotic adherence (OR 0.4). In severe sepsis, only compliance to antibiotic adherence plus first dose within 6 h was associated with lower mortality (OR 0.60), adjusted for fine prognostic scale and hospital. Antibiotic adherence was related to shorter hospital stay. In sepsis, antibiotic adherence is the strongest protective factor of care associated with survival and LOS. In severe sepsis, combined antibiotic adherence and first dose within 6 h may reduce mortality.

Utility of two biomarkers for directing care among patients with non-severe community-acquired pneumonia.

The aim of the present study is to evaluate the usefulness of two biomarkers-procalcitonin (PCT) and C-reactive protein (CRP)-in addition to the CURB-65 score for assessing the site of care and the etiology of non-severe community-acquired pneumonia (CAP). We conducted a prospective observational study from April 1, 2006, to June 30, 2007, in a single teaching hospital in northern Spain among patients with non-severe CAP. In addition to collecting data needed to determine the CURB-65 score, microbial cultures were taken and levels of PCT and CRP were measured. We compared the prognostic accuracy of these biomarkers with the CURB-65 score to predict hospitalization and microbial etiology using receiver operating characteristic (ROC) curves. A total of 344 patients with non-severe CAP were enrolled; 73 were admitted to the hospital and 271 were treated on an outpatient basis. An etiologic diagnostic was made for 44 %, with atypical pathogens predominating. Levels of PCT and CRP increased with increasing CURB-65 scores. Patients admitted to the hospital had higher PCT and CRP levels than outpatients (p < 0.001). For predicting hospitalization, PCT had a better area under the ROC curve (AUC) (0.81) than the CURB-65 score alone (0.77). For PCT plus the CURB-65 score, the AUC increased significantly from 0.77 to 0.83. In patients with bacterial CAP, the biomarker levels were significantly higher than among patients with atypical or viral etiology (p < 0.001). PCT with a cut-off point of 0.15 ng/mL was the best predictor for bacterial etiology and for select patients eligible for outpatient care. In conclusion, levels of PCT and CRP positively correlate with increasing severity of CAP and may have a role in predicting both patients who can safely receive outpatient care and the microbial etiology in patients with low CURB-65 scores.

Score to identify the severity of adult patients with influenza A (H1N1) 2009 virus infection at hospital admission.

The objective of this paper was to develop a prognostic index for severe complications among hospitalized patients with influenza A (H1N1) 2009 virus infection. We conducted a prospective observational cohort study of 618 inpatients with 2009 H1N1 virus infection admitted to 36 Spanish hospitals between July 2009 and February 2010. Risk factors evaluated included host-related factors and clinical data at admission. We developed a composite index of severe in-hospital complications (SIHC), which included: mortality, mechanical ventilation, septic shock, acute respiratory distress syndrome, and requirement for resuscitation maneuvers. Six factors were independently associated with SIHC: age >45 years, male sex, number of comorbidities, pneumonia, dyspnea, and confusion. From the ß parameter obtained in the multivariate model, a weight was assigned to each factor to compute the individual influenza risk score. The score shows an area under the receiver operating characteristic (ROC) curve of 0.77. The SIHC rate was 1.9 % in the low-risk group, 10.3 % in the intermediate-risk group, and 29.6 % in the high-risk group. The odds ratio for complications was 21.8 for the high-risk group compared with the low-risk group. This easy-to-score influenza A (H1N1) 2009 virus infection risk index accurately stratifies patients hospitalized for H1N1 virus infection into low-, intermediate-, and high-risk groups for SIHC.

Development of a decision tree to assess the severity and prognosis of stable COPD.

The aim of this study was to develop and validate a new method: a classification and regression tree (CART) based on easily accessible measures to predict mortality in patients with stable chronic obstructive pulmonary disease (COPD). This was a prospective study of two independent prospective cohorts: a derivation cohort with 611 recruited patients and a validation cohort with 348 patients, all followed for 5 yrs. CART analysis was used to predict 5-yr mortality risk using the following covariates from the derivation cohort: age, % predicted forced expiratory volume in 1 s (FEV(1)), dyspnoea, physical activity, general health and number of hospital admissions for COPD exacerbations in the previous 2 yrs. Age (≥ 75 or <75 yrs) provided the first branch of the COPD-CART. The highest mortality risk (0.74) was seen in patients >75 yrs of age with higher levels of dyspnoea and FEV(1) <50% pred. Patients with the lowest risk of 5-yr mortality (0.04) were <55 yrs of age with FEV(1) >35% pred and one or no recent hospitalisations for COPD exacerbations. A simple decision tree that uses variables commonly gathered by physicians can provide a quick assessment of the severity of the disease, as measured by the risk of 5-yr mortality.

Impact of changes in physical activity on health-related quality of life among patients with COPD.

The aim of this study was to evaluate whether changes in regular physical activity (PA) affect health-related quality of life (HRQoL) among patients with chronic obstructive pulmonary disease (COPD). 611 patients (mean age 67.2+/-8.4 yrs; forced expiratory volume in 1 s 49.7+/-14.6) completed the St George's Respiratory Questionnaire (SGRQ), the Chronic Respiratory Questionnaire (CRQ) and the Medical Outcomes Short Form (SF-36) questionnaire. PA, defined as patients' self-reported regular walking times, was classified as low, moderate and high. After 5 yrs, 391 survivors completed these instruments again. After adjustment for relevant confounders, patients who reported low PA at baseline and who increased their PA over the study period improved their SGRQ and CRQ scores by 15.9 and 8.7 points, respectively. Patients who moved from moderate to high PA improved their SGRQ scores by 18.4 and their CRQ scores by 14.8. Slightly smaller increases were observed for patients who maintained a high level of PA throughout the study period. Maintaining a low level of PA or decreasing PA over the study period was associated with a significant HRQoL decline. Among COPD patients, a reduction in time spent engaging in PA or maintaining a low level may impair HRQoL, whereas an increase in PA can improve HRQoL parameters.

Development of a prognostic index for 90-day mortality in patients discharged after admission to hospital for community-acquired pneumonia.

BACKGROUND: Although patients admitted to hospital for community-acquired pneumonia (CAP) experience substantial short-term mortality following hospital discharge, few studies have focused on identifying factors that predict mortality after admission to hospital in this population. The objective of this study was to develop and validate a prognostic index for 90-day mortality after hospital discharge among patients with CAP. METHODS: The prognostic index was derived in 1117 adult patients discharged between 2003 and 2007 from a general hospital following admission for CAP. It was validated in 646 consecutive patients with CAP discharged from three other hospitals between 1 November 2005 and 31 July 2006. Risk factors evaluated included host-related factors, severity upon admission, in-hospital management and bacteriology. RESULTS: In the derivation cohort, three factors were independently associated with 90-day mortality: pre-illness functional status, Charlson index (composite measure of co-morbid illnesses) and severity on admission. Mortality at 90 days was 0.7% in the low-risk group, 3.5% in the intermediate-risk group and 17.2% in the high-risk group. In the validation cohort, 90-day mortality in the three groups was 0.6%, 3.9% and 19.6%, respectively. Compared with the low-risk group, the odds ratio for mortality was 43.5 for the high-risk group. The risk categories showed an area under the receiver operating characteristic curve of 0.79 in the derivation cohort and 0.82 in the validation cohort. CONCLUSIONS: The prognostic index accurately stratifies patients admitted to hospital for CAP into low-, intermediate- and high-risk groups for 90-day mortality on discharge. The use of this index could help clinicians improve outcomes in this vulnerable population by targeting specific interventions to each group.

Classifying the severity of COPD: are the new severity scales better than the old?

BACKGROUND: Forced expiratory volume in 1 second cut-off points establish the severity of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To compare how the American Thoracic Society (ATS), the British Thoracic Society (BTS), the Global Initiative for COPD (GOLD) and the ATS-European Respiratory Society (ATS-ERS) guidelines for rating COPD severity predict several significant outcomes. DESIGN: Five-year prospective cohort study. Spirometry was performed and health-related quality of life (HRQoL) assessed using the Short Form 36 Health Survey and the Saint George's Respiratory Questionnaire. Hospital admissions resulting from COPD exacerbation and mortality during a 5-year follow-up period were recorded. RESULTS: In all guidelines, the number of admissions was directly associated with COPD severity. The sensitivity and specificity for 5-year respiratory mortality were respectively 0.21 and 0.97 for the GOLD/ATS-ERS, 0.51 and 0.79 for the BTS, and 0.37 and 0.89 for the ATS guidelines. A similar pattern was seen for all-cause mortality. For HRQoL, statistically significant differences between guidelines were seen only for the BTS and ATS scales. CONCLUSIONS: These guidelines did not consistently stratify patients with regard to 5-year mortality and HRQoL. Although the BTS system was slightly superior, none of the guidelines were closely related to these outcomes. Other instruments are needed for a better determination of the severity of COPD.

A simple score for assessing stable chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is usually assessed using FEV(1) to establish the diagnosis and the severity of the disease. However, COPD is now considered a systemic disease. AIM: To evaluate the utility of the Health-Activity-Dyspnoea-Obstruction (HADO) score for classifying the severity of COPD and predicting outcomes. DESIGN: Prospective longitudinal clinical study. METHODS: We studied 611 consecutive patients with stable COPD in five out-patient clinics of a teaching hospital. We measured dyspnoea degree, pulmonary function (by spirometry), self-reported level of daily physical activity and overall health condition. Outcome measures included health-related quality of life (HRQoL) parameters (as measured by the generic SF-36 Health Survey and by two specific questionnaires, the St George Respiratory Questionnaire and the Chronic Respiratory Questionnaire) and mortality at 3 years follow-up. RESULTS: Based on the HADO score, COPD was classified as mild in 26.7% of patients, moderate in 53.3%, and severe in 20%. There were statistically significant correlations between these three levels of severity and HRQoL parameters and vital status. After adjustment for relevant covariates, the HADO score reliably predicted survival and vital status. DISCUSSION: The HADO score can be easily obtained in an out-patient clinic, and distinguishes groups of COPD patients by their disease severity. The HADO score is better than FEV(1%) alone for predicting mortality at 3 years.

[Patients hospitalized with community-acquired pneumonia: a comparative study of outcomes by medical specialty area]. / Pacientes ingresados por neumonía adquirida en la comunidad: estudio comparativo en función de la especialidad del servicio médico responsable.

OBJECTIVE: Variability in the management of patients hospitalized with community-acquired pneumonia (CAP) is attributable to many factors. The objective of this study was to determine whether such variability is influenced by the medical specialty area where the patient is treated. PATIENTS AND METHODS: The treatment and outcomes for a random sample of patients with CAP admitted to 4 hospitals over 2 periods (1 year starting March 1, 1998, and 1.5 years starting March 1, 2000) were compared by medical specialty department. Multiple linear and logistic regression models were used to analyze differences. RESULTS: Differences were found between departments in the coverage of atypical pathogens (P<.001). The adjusted mean length of stay in hospital varied between 6.8 and 9.1 days (P<.01), and the duration of intravenous treatment varied between 4.6 and 7.3 days (P<.05). Adjusted models showed that mortality in hospital and at 30 days was significantly higher for patients treated in internal medicine departments (odds ratios, 2.1 and 2, respectively) than for those treated in pulmonology departments. CONCLUSIONS: Interdepartmental differences were observed in how patients hospitalized with CAP were treated and in the outcomes achieved. This variation is probably influenced by the differences that were found in the use of antibiotics.

Resolution of a brainstem abscess through antituberculous therapy.

We describe an immunocompetent patient with a solitary brainstem abscess that responded to antituberculous therapy. Although prompt surgical therapy has been advocated, the possibility of medical resolution of brainstem tuberculous abscesses should be considered.

Magnetic resonance cholangiopancreatography in the evaluation of pancreatic duct pathology.

MR cholangiopancreatography (MRCP) may replace direct pancreatography in the evaluation of the pancreatic duct. The aim of this pictorial review is to demonstrate the usefulness of MRCP in the evaluation of pancreatic duct pathology. The examination technique included coronal, sagittal and axial breath-hold HASTE 2D imaging using a body phase array coil. We present the diagnostic features on MRCP of a variety of benign and malignant disorders of the pancreatic duct, and conclude that MRCP is a suitable method for imaging the pancreatic duct system.

[Description of a sample of patients with chronic obstructive pulmonary disease treated at hospital-supervised respiratory clinics at primary care centers]. / Descripción de una muestra de pacientes con enfermedad pulmonar obstructiva crónica atendidos en las consultas del área de neumología dependientes de un hospital.

OBJECTIVE: To study the general characteristics, health perception and limitations of patients with chronic obstructive pulmonary disease (COPD) treated at respiratory clinics at primary care centers staffed by pulmonologists from our hospital service. METHOD: The study was carried out at 5 primary care centers that enrolled the patients consecutively. Questionnaires were used to collect information on sociodemographic aspects, perception of health, and limitations to activities of daily living. We also collected information on the treatments patients were receiving and comorbidities. Spirometry was also performed. RESULTS: Six hundred eleven patients with a mean age of 67.2 years were included in the study; 97.7% were male. The most common comorbidities were spinal column pathology (43%) and osteoarthritis (37%). The mean forced expiratory volume in 1 second (FEV1) was 1.37 L and FEV1% was 49.7% of predicted. Medications taken for COPD were mainly beta-adrenergics and anticholinergics; 66% of patients used inhaled steroids. The majority of patients (52.7%) referred to their health as fair and 59.9% declared having some degree of limitation to their activities of daily living which they attributed to their respiratory disease. Statistical differences were found between the degree of limitation and the degree of dyspnea (P<.0001), perception of health (P<.0001), and FEV1 (P=.001). CONCLUSIONS: Our study outlines the general characteristics of COPD patients and shows that dyspnea is closely related to the perception patients have of their degree of limitation.

[The gammagraphic diagnosis of acute pulmonary thromboembolism]. / Diagnóstico gammagráfico del tromboembolismo pulmonar agudo.

We aimed to determine the prevalence of acute pulmonary embolism (APE) in our population and to establish the diagnostic reliability of pulmonary scintigraphy (PS), as well as the influence of the clinical context (CC). During a 2-year prospective study, patients were diagnosed by either pulmonary angiography or normal-perfusion PS. A diagnosis of APE was made in 73 (75%) of a total of 97 patients. In the group of 58 patients diagnosed by ventilation/perfusion (V/Q) PS, 33 were classified as "highly probably" having APE; 32 of these in fact had the syndrome (sensitivity 88%, specificity 94%). Combining the "highly probable" patients with the "highly suspected" patients diagnosed by ventilation/perfusion PS, we obtained a sensitivity of 51% and specificity of 100%. Ventilation scintigrams were unobtainable in 28 older patients with greater dyspnea and tachypnea, who were unable to perform the maneuvers. Of the 21 "highly probable" patients as assessed by PS, 19 were diagnosed as having APE (sensitivity 86%, specificity 85%). Combining the "highly probable" patients with the "highly suspected" group, we obtained a sensitivity of 32% and specificity of 100%. Normal perfusion PS excludes clinically relevant APE. "Intermediate" or "slight" probability PS results, even when combined with CC, have no diagnostic validity.

[Reference figures for pulmonary artery pressures after effective treatment of Graves' disease]. / Normalización de las cifras de presión en la arteria pulmonar tras tratamiento efectivo de la enfermedad de Graves.

We report the case of a 48-year-old woman with a diagnosis of pulmonary hypertension and hyperthyroidism (Graves' disease) in whom pulmonary artery pressures became normal after treatment of thyroid disease. The possible pathogenic mechanisms involved in this association include the presence of hyperdynamic heart failure and/or the presence of immune alterations underlying both conditions.

[Association between the forced midexpiratory flow/forced vital capacity ratio and bronchial hyperresponsiveness]. / Asociación entre el cociente FEF(25-75%)/FVC y la hiperreactividad bronquial.

OBJECTIVE: A long-standing hypothesis is that a low ratio of airway caliber to lung size is associated with bronchial hyperresponsiveness (BHR). The aim of our study was to measure the association between airway caliber relative to lung size (expressed as the ratio between forced expiratory flow, midexpiratory phase, divided by forced vital capacity [FEF(25%-75%)/FVC]) and BHR measured by a methacholine challenge test, adjusting for age, height, sex, smoking history, geographic area, respiratory symptoms, and baseline forced expiratory volume in 1 second (FEV1). MATERIAL AND METHODS: We carried out a multicenter cross-sectional study of the general Spanish population in 2647 subjects from the European Community Respiratory Health Survey (ECRHS I). The ECRHS questionnaire was administered, total and specific immunoglobulin E were measured, and skin tests, spirometry, and a methacholine challenge test were performed. RESULTS: We show the relationship of the various clinical and sociodemographic variables with the 2 parameters indicative of a positive methacholine test. The lower the FEF(25%-75%)/FVC ratio was, the greater the risk of HRB, after adjustment for variables (odds ratio [OR]=0.09; 95% confidence interval [CI], 0.04-0.018 for the concentration provoking a 20% decrease in FEV1, and OR=0.06; 95% CI, 0.03-0.12 for the dose provoking a 20% decrease in FEV1). CONCLUSIONS: There is a significant association between the FEF(25%-75%)/FVC ratio and BHR after adjustment for age, atopy, smoking, geographic area, respiratory symptoms, and initial FEV1.