Decreasing trend in the incidence of serious pneumonias in Finnish children with juvenile idiopathic arthritis.

OBJECTIVES: Children with juvenile idiopathic arthritis (JIA) may be predisposed to serious pneumonia due to modern disease-modifying anti-rheumatic treatment. In this nationwide retrospective study with clinical data, we describe the pneumonia episodes among children with JIA. METHODS: Patients under 18 years of age with JIA and pneumonia during 1998-2014 were identified in the National Hospital Discharge Register in Finland. Each individual patient record was reviewed, and detailed data on patients with JIA and pneumonia were retrieved, recorded, and analyzed. If the patient was hospitalized or received intravenous antibiotics, the pneumonia was considered serious. RESULTS: There were 157 episodes of pneumonia among 140 children with JIA; 111 episodes (71%) were serious (80% in 1998-2006 and 66% in 2007-2014). The mean age of the patients was 9 years. Forty-eight percent had active JIA and 46% had comorbidities. Disease-modifying anti-rheumatic drugs (DMARD) were used at the time of 135 episodes (86%): methotrexate (MTX) by 62% and biologic DMARDs (bDMARD) by 30%. There was no significant difference in the use of bDMARDs, MTX and glucocorticoids between the patient groups with serious and non-serious pneumonia episodes. During six of the episodes, intensive care was needed. Two patients (1.3%) died, the remaining ones recovered fully. CONCLUSIONS: Although the incidence of pneumonia and the use of immunosuppressive treatment among children with JIA increased from 1998 to 2014, the proportion of serious pneumonias in these patients decreased. There was no significant difference in the use of anti-rheumatic medication between patients with serious and non-serious pneumonia.Key Points• The incidence of serious pneumonias decreased from 1998 to 2014 among children with juvenile idiopathic arthritis (JIA).• There was no significant difference in the use of the disease-modifying anti-rheumatic medication between JIA patients with serious and non-serious pneumonias.• Active JIA, comorbidities, and combination medication were associated with nearly half of the pneumonias.

Pneumonia in children with juvenile idiopathic arthritis in Finland 1999-2014: a nationwide retrospective register linkage study.

OBJECTIVES: To compare the incidence of pneumonia in children with juvenile idiopathic arthritis (JIA) to the aged-matched general population and to evaluate the use of anti-rheumatic medication among children with JIA and pneumonia. METHODS: The National Hospital Discharge Register collects data on ICD-diagnoses of hospital patients in Finland. From this register, patients with JIA under 18 years of age with pneumonia from 1999 through 2014 were identified. The control group consisted of age-matched patients derived from the general population with a diagnosis of pneumonia made in the same calendar year as the pneumonia of the JIA patients. The patient records of the children with JIA were scrutinised for the use of anti-rheumatic medication. RESULTS: We identified 223 pneumonias among the JIA patients (56,161 patient-years) and 53,058 pneumonias in the control group (17,546,609 person-years). The incidence of pneumonia in children with JIA was 386 (annual range 131-639) and in the control group 303 (annual range 225-438) per 100,000 person-years. The incidence of pneumonia increased significantly over time among JIA patients (p=0.013) and in the control group (p<0.001). Through 2007-2014 the rate of pneumonia was significantly higher among children with JIA (p<0.001) than control children. We found 150 JIA patients with pneumonia confirmed by positive chest radiograph. Altogether 47% of the JIA patients had combination medication. The use of methotrexate and biologic agents increased significantly over time (p=0.016 and p<0.001, respectively). CONCLUSIONS: The incidence of pneumonia increased in children with JIA and in the general population from 1999 to 2014. During 2007-2014 JIA patients had a significantly higher rate of pneumonia than age-matched controls. The use of active anti-rheumatic medication was common.

A history of diabetes but not hyperglycaemia during exacerbation of obstructive lung disease has impact on long-term mortality: a prospective, observational cohort study.

OBJECTIVE: Hyperglycaemia is very common during exacerbations of asthma and chronic obstructive pulmonary disease (COPD). However, its clinical significance is not clear. The objective of the present study was to assess whether exacerbation-associated hyperglycaemia affects long-term mortality in these patients. DESIGN: A prospective, observational cohort study. SETTING: A single hospital in eastern Finland. PARTICIPANTS: 153 consecutive patients who were hospitalised due to mild to moderate obstructive lung disease exacerbation (110 with asthma and 43 with COPD) and who survived at least 30 days. INTERVENTIONS: Plasma glucose levels were recorded seven times during the first day on the ward. Several possible confounders were also recorded. The median follow-up time was 6 years and 2 months. RESULTS: During the follow-up, 57 (37%) of the patients died. Previously diagnosed diabetes was strongly associated with elevated mortality (adjusted HR (aHR) 3.03 (1.28 to 7.18). The highest fasting glucose value (aHR 1.10 (1.01 to 1.20) per 1 mmol/L) and the highest postprandial glucose value ((aHR 1.07 (1.00 to 1.16)) were also associated with late mortality. However, the associations between highest glucose values and mortality vanished when the diagnosis of diabetes was included in the same model. Within the patients without diabetes, neither fasting (aHR 0.92 (0.42 to 2.02)) nor postprandial ((aHR 1.04 (0.50 to 2.12)) hyperglycaemia was associated with late mortality. There were no statistically significant differences in the underlying causes of death between the patients with and without diabetes. CONCLUSION: A history of diabetes but not hyperglycaemia during exacerbation of obstructive lung disease has impact on long-term mortality.

Plasma amino-terminal pro B-type natriuretic peptide as a predictor of late cardiovascular mortality in patients with acute lung disorders: a prospective, observational cohort study.

AIMS: Pneumonia and acute exacerbations of obstructive lung diseases (AEOLD) are associated with a significant long-term mortality. Elevated level of amino-terminal pro B-type natriuretic peptide (NT-proBNP) is a predictor of late all-cause mortality in these disorders but the pathophysiological basis for this is unknown. The present study was conducted to define the predictive role of NT-proBNP on late cardiovascular mortality among patients with acute lung disorders. METHODS AND RESULTS: This prospective, observational cohort study included 269 hospitalized patients with pneumonia or AEOLD. Plasma level of NT-proBNP, age, sex, body mass index, arterial blood oxygen saturation, C-reactive protein, and urea were recorded. The survival and causes of death were recorded after a median of six years. NT-proBNP > 666 ng/mL was related to cardiovascular mortality with an adjusted hazard ratio of 2.93 (1.19-7.18). This risk was of similar magnitude to that associated with diabetes and greater than that associated with arterial hypertension, hypercholesterolemia, and smoking. NT-proBNP was also related to all-cause mortality with adjusted hazard ratio of 2.39 (1.49-3.85) per 10 times increase in NT-proBNP concentration. However, the association between NT-proBNP and non-cardiovascular mortality did not reach statistical significance [adjusted hazard ratio 1.89 (0.93-3.85)]. CONCLUSION: NT-proBNP concentration during pneumonia or AEOLD was strongly associated with late cardiovascular mortality but not with non-cardiovascular mortality. The results suggest that the increase in NT-proBNP during acute lung disorders may reveal occult cardiac diseases arousing a question whether patients with acute pulmonary disorders with elevated NT-proBNP levels should be subjected to further diagnostic or therapeutic cardiovascular interventions.

Bloodstream infections among children with juvenile idiopathic arthritis: a prospective study from the onset of disease.

OBJECTIVES: To describe the incidence and nature of bloodstream infections (BSI) among children with juvenile idiopathic arthritis (JIA) followed-up prospectively from disease onset. METHODS: The Social Insurance Institution's (SII) national register on individuals with reimbursement for medication of chronic diseases was used to identify children with JIA from 2004 through 2011 and their medications. The National Infectious Disease Register (NIDR) collects data of all blood culture positive samples from all microbiology laboratories in Finland. We combined the NIDR and SII registers to identify JIA patients with BSI. Clinical and laboratory data of each JIA-BSI patient were collected from hospital records. RESULTS: There were 1604 JIA patients and 6630 person-years of follow-up. Five patients had BSI. During the first 5 years after diagnosis the cumulative emergence of BSI was 0.38% [95% confidence interval (CI) 0.16% to 0.92%]. The incidence rates were 7.5/10 000 follow-up years for JIA (95% CI 2.4-17.6) and 2.8/10 000 follow-up years for the age-matched general population (95% CI 2.7-2.9). The standardised incidence ratio was 3.0 (95% CI 1.2 to 7.2). The causative bacteria were Streptococcus pneumoniae, Staphylococcus aureus, Escherichia coli and Fusobacterium necrophorum. Three patients were on anti-rheumatic drugs, including two on TNF inhibitors. All patients responded rapidly to antimicrobial therapy and recovered uneventfully. CONCLUSIONS: Although BSI is rare among children with JIA, the incidence is 3-fold higher than among the general population.

Long-term mortality after community-acquired pneumonia--impacts of diabetes and newly discovered hyperglycaemia: a prospective, observational cohort study.

OBJECTIVES: Community-acquired pneumonia is associated with a significant long-term mortality after initial recovery. It has been acknowledged that additional research is urgently needed to examine the contributors to this long-term mortality. The objective of the present study was to assess whether diabetes or newly discovered hyperglycaemia during pneumonia affects long-term mortality. DESIGN: A prospective, observational cohort study. SETTING: A single secondary centre in eastern Finland. PARTICIPANTS: 153 consecutive hospitalised patients who survived at least 30 days after mild-to-moderate community-acquired pneumonia. INTERVENTIONS: Plasma glucose levels were recorded seven times during the first day on the ward. Several possible confounders were also recorded. The surveillance status and causes of death were recorded after median of 5 years and 11 months. RESULTS: In multivariate Cox regression analysis, a previous diagnosis of diabetes among the whole population (adjusted HR 2.84 (1.35-5.99)) and new postprandial hyperglycaemia among the non-diabetic population (adjusted HR 2.56 (1.04-6.32)) showed independent associations with late mortality. New fasting hyperglycaemia was not an independent predictor. The mortality rates at the end of follow-up were 54%, 37% and 10% among patients with diabetes, patients without diabetes with new postprandial hyperglycaemia and patients without diabetes without postprandial hyperglycaemia, respectively (p<0.001). The underlying causes of death roughly mirrored those in the Finnish general population with a slight excess in mortality due to chronic respiratory diseases. Pneumonia was the immediate cause of death in just 8% of all late deaths. CONCLUSIONS: A previous diagnosis of diabetes and newly discovered postprandial hyperglycaemia increase the risk of death for several years after community-acquired pneumonia. As the knowledge about patient subgroups with an increased late mortality risk is gradually gathering, more studies are needed to evaluate the possible postpneumonia interventions to reduce late mortality.

Hyperglycaemia during exacerbations of asthma and chronic obstructive pulmonary disease.

INTRODUCTION: Hyperglycaemia is a well-known phenomenon among patients with an exacerbation of asthma or chronic obstructive pulmonary disease (COPD). It may be associated with increased risks of death and complications. OBJECTIVES: To define the prevalence and determinants of hyperglycaemia in patients with an exacerbation of asthma or COPD. METHODS: This was a prospective, cross-sectional study including 153 hospitalised patients with an exacerbation of asthma or COPD. All received inhaled beta-2-adrenergic bronchodilators and oral glucocorticoids in internationally recommend doses. Plasma glucose was measured seven times during the first day. Hyperglycaemia was defined as fasting glucose >6.9 mmol/L or postprandial glucose >11.1 mmol/L. In addition, the family history for diabetes and the Karnofsky performance score were assessed. Height, weight, waist circumference, oxygen saturation, blood pressure, temperature and heart rate were measured. Glycosylated haemoglobin A1c (gHbA1c), C-reactive protein, leucocytes, urea and arterial blood gas values were analysed. RESULTS: Eighty-two per cent of the patients demonstrated hyperglycaemia, with similar prevalence between asthma and COPD. Of the 130 patients without a previous diagnosis of diabetes, 79% showed hyperglycaemia. In binary logistic regression analysis, high gHbA1c, high C-reactive protein and Karnofsky score less than 80% associated with the presence of fasting hyperglycaemia. High gHbA1c and current smoking associated with postprandial hyperglycaemia. CONCLUSIONS: Hyperglycaemia is very common among hospitalised patients with an exacerbation of asthma or COPD. It is probably triggered by the medication and the patient's metabolic predisposition mainly determines its presence. Current smoking is the main treatable contributor to hyperglycaemia.

Prevalence and determinants of hyperglycaemia in pneumonia patients.

BACKGROUND: Hyperglycaemia during pneumonia prolongs the hospitalization and increases the risks of complications and death. However, its prevalence and determinants have not been systematically assessed. METHODS: This was a prospective, cross-sectional study. The material consisted of 153 hospitalized patients with pneumonia. Patients needing intensive care unit treatment were excluded. The height, weight, waist circumference, oxygen saturation, blood pressure, temperature, heart rate, and Karnofsky score were measured at admission. Blood tests included glycosylated haemoglobin A1c (gHbA1c), C-reactive protein (CRP), leukocytes, urea, and arterial blood gas analysis. Plasma glucose was measured 7 times during the first day on the ward. Hyperglycaemia was defined as a fasting glucose > 7.0 mmol/l or postprandial glucose > 11.1 mmol/l. RESULTS: Ninety-two patients (60%) showed hyperglycaemia. Twenty-two patients had a diagnosis of diabetes before hospitalization. Of the 131 patients without such a diagnosis, 72 (55%) showed hyperglycaemia. Of these, 67 showed fasting hyperglycaemia and 36 postprandial hyperglycaemia. In the binary logistic regression analysis, the following factors showed independent associations with the presence of hyperglycaemia: advanced age, high gHbA1c, high CRP, and high blood leukocyte level. CONCLUSIONS: More than half of non-diabetic patients with mild to moderate pneumonia demonstrated hyperglycaemia. The main determinants of hyperglycaemia were an abnormal pre-pneumonia glucose metabolism and the intensity of the pneumonic inflammation. Systematic screening of hyperglycaemia in all hospitalized pneumonia patients appears reasonable to identify high-risk patients.