Facility characteristics as independent prognostic factors of nursing home-acquired pneumonia

BACKGROUND/AIMS: Recently, the incidence of nursing home-acquired pneumonia (NHAP) has been increasing and is now the leading cause of death among nursing home residents. This study was performed to identify risk factors associated with NHAP mortality, focusing on facility characteristics. METHODS: Data on all patients > or = 70 years of age admitted with newly diagnosed pneumonia were reviewed. To compare the quality of care in nursing facilities, the following three groups were defined: patients who acquired pneumonia in the community, care homes, and care hospitals. In these patients, 90-day mortality was compared. RESULTS: Survival analyses were performed in 282 patients with pneumonia. In the analyses, 90-day mortality was higher in patients in care homes (12.2%, 40.3%, and 19.6% in community, care homes, and care hospitals, respectively). Among the 118 NHAP patients, residence in a care home, structural lung diseases, treatment with inappropriate antimicrobial agents for accompanying infections, and a high pneumonia severity index score were risk factors associated with higher 90-day mortality. However, infection by potentially drug-resistant pathogens was not important. CONCLUSIONS: Unfavorable institutional factors in care homes are important prognostic factors for NHAP.

Large Coronary Artery Aneurysm with Thrombotic Coronary Occlusion Resulting in ST-Elevation Myocardial Infarction after Warfarin Interruption

A 44-year-old man, who had a history of myocardial infarction (MI) due to thrombotic occlusion of right coronary artery (RCA) aneurysm, visited emergency department presenting with ST-segment elevation myocardial infarction (STEMI). The patient had been on oral anticoagulant therapy (warfarin) from the first thrombotic event, but the medication had been recently changed to aspirin 4 months before the second event. Emergent coronary angiography revealed thrombotic total occlusion of RCA with heavy thrombotic burden from middle RCA to the ostium of the posterior descending branch. Combination pharmacotherapy was performed with anticoagulants (heparin), fibrinolytics (urokinase), and Glycoprotein IIb/IIIa antagonists (abciximab), in addition to mechanical thrombosuction. However, on hospital day 2, the patient complained recurrent chest pain and again underwent coronary angiography, which revealed distal embolization of large thrombus to the posterior lateral branch. Coronary flow was recovered after repeated mechanical thrombosuction was performed. This case has shown the importance of aggressive combination drug therapy, accompanied by mechanical thrombosuction in patient with myocardial infarction due to thrombotic occlusion of coronary artery aneurysm and the importance of unceasing life-long anticoagulant therapy in those particular patients.

Endovascular Management of Spontaneous Superficial Femoral Artery Pseudoaneurysm in a Renal Allograft Patient

We report a case of a superficial femoral artery pseudoaneurysm in 52-year old patient with a history of having renal allograft. The pseudoaneurysm spontaneously developed while standing up from squatting position after defecation, and it was successfully managed by an endovascular repair with an endograft. This case suggests that an atherosclerotic superficial femoral artery is vulnerable to torsion and tension movement during changing position from squatting to standing, which is repeatedly practiced by the people using the Korean traditional toilet. The endovascular therapy is also recommended for elderly patients with poor clinical conditions such as having a renal allograft and diffuse atherosclerosis of peripheral arteries.