Factores pronósticos de la neumonía comunitaria. Estudio prospectivo multicéntrico en Servicios de Medicina Interna / Prognostic factors in community acquired pneumonia. Prospective multicenter study in internal medical departments

Objetivo: Los objetivos de este estudio multicéntrico fueron evaluar las características clínicas y microbiológicas de pacientes que ingresaron en servicios de Medicina Interna y analizar los factores que influyeron en la mortalidad a los 30 días. Método: Se recogieron antecedentes personales de cada paciente, síntomas y signos, patrón radiológico y parámetros analíticos incluyendo albúmina y proteína C reactiva (PCR). También se registró el número de horas que transcurrieron hasta que se instauró la primera dosis de antibiótico y el seguimiento en días. Los pacientes fueron estratificados en cinco clases de riesgo según el Pneumonia Severity Index. Resultados: Se incluyeron 389 pacientes la mayoría distribuidos en las clase III a V de Fine. La mortalidad global fue del 12,1% (48 pacientes) elevándose al 40% en los pacientes de la clase V. Ni la edad, ni el sexo, ni el número de horas transcurrido hasta la primera dosis de tratamiento antibiótico influyeron en la mortalidad a los 30 días. Tampoco los niveles de PCR en plasma ni el conocer o no el diagnóstico microbiológico. Los pacientes orientados (OR 0,138, IC95% 0,055-0,324)y con mayores niveles de albúmina (OR 0,207, IC95% 0,103-0,417) tuvieron mejor supervivencia .La presencia de carcinoma activo (OR 3,2, IC95% 1,181-8,947) predijo tambien de forma independiente la mortalidad. Conclusiones: Concluimos que además de los parámetros universalmente aceptados de Fine, debería utilizarse la albúmina para seleccionar a aquellos pacientes en los que el pronóstico podría ser peor

Aims: the aims of the present study were to evaluate the clinical and microbiological characteristics of patients suffering from communityacquired pneumonia attended in the Internal Medical Departments of several Spanish institutions and to analyze those prognostic factors predicting thirty-day mortality in such patients. Material and methods: Past medical history, symptoms and signs, radiological pattern and blood parameters including albumin and C Reactive Protein, were recorded for each patient. Time from admission to starting antibiotics (in hours) and follow-up (in days) were also recorded. Patients were stratified by the Pneumonia Severity Index in five risk classes. Results: 389 patients were included in the study, most of them in Fine categories III to V. Mortality rate for all patients was 12.1% (48 patients), increasing up to 40% in Fine Class V. Neither age, sex nor time from admission to the start of antibiotic treatment predicted survival rates. Plasmatic levels of PCR or microbiologic diagnosis were not related to clinical outcome. In the Cox regression analysis, oriented patients (OR 0.138, IC95% 0.055-0.324), and those with normal albuminemia (OR 0.207, IC95% 0.103-0.417) showed better survival rates. On the contrary, those with active carcinoma (OR 3.2, IC95% 1.181-8.947) significantly showed a reduced life expectancy. Conclusion: Besides the fully accepted Fine scale criteria, albumin measurements should be included in routine evaluation in order to improve patient’s prognostic classification

[Prognostic factors in community acquired pneumonia. Prospective multicenter study in internal medical departments]. / Factores pronósticos de la neumonía comunitaria. Estudio prospectivo multicéntrico en Servicios de Medicina Interna.

AIMS: the aims of the present study were to evaluate the clinical and microbiological characteristics of patients suffering from community-acquired pneumonia attended in the Internal Medical Departments of several Spanish institutions and to analyze those prognostic factors predicting thirty-day mortality in such patients. MATERIAL AND METHODS: Past medical history, symptoms and signs, radiological pattern and blood parameters including albumin and C Reactive Protein, were recorded for each patient. Time from admission to starting antibiotics (in hours) and follow-up (in days) were also recorded. Patients were stratified by the Pneumonia Severity Index in five risk classes. RESULTS: 389 patients were included in the study, most of them in Fine categories III to V. Mortality rate for all patients was 12.1% (48 patients), increasing up to 40% in Fine Class V. Neither age, sex nor time from admission to the start of antibiotic treatment predicted survival rates. Plasmatic levels of PCR or microbiologic diagnosis were not related to clinical outcome. In the Cox regression analysis, oriented patients (OR 0.138, IC95% 0.055-0.324), and those with normal albuminemia (OR 0.207, IC95% 0.103-0.417) showed better survival rates. On the contrary, those with active carcinoma (OR 3.2, IC95% 1.181-8.947) significantly showed a reduced life expectancy. CONCLUSION: Besides the fully accepted Fine scale criteria, albumin measurements should be included in routine evaluation in order to improve patient s prognostic classification.

Supervivencia y progresión de la enfermedad en 251 pacientes con infección por el VIH-1. Estudio del antígeno p24 y de la carga viral como marcadores pronóstico. Su valor a los 4 años de seguimiento / Survival and progression in 251 patients with HIV-1 disease. Study of p24 antigen and viral load as surro gate markers. Their utility in 4 years of follow-up

Fundamento: Analizar el valor de los niveles plasmáticos de antígeno p24 y la carga viral (RNA, PCR), como marcadores pronóstico en una cohorte de pacientes infectados por el VIH-1, cuyo tiempo de seroconversión es desconocido.Pacientes: Se incluyeron 251pacientes, la mayoría con terapia antirretroviral, que fueron asistidos de forma consecutiva en la Unidad VIH/SIDA del Servicio de Medicina Interna del Hospital Universitario Arnau de Vilanova de Lleida.Métodos: Se hicieron estudios clínico-analíticos en el momento de inclusión (basal) y luego, cada 3 meses.En relación al antígeno p24, se establecieron 3 grupos: Grupo I, 40 pg/mL).Respecto al estudio de progresión, 34 pacientes lo hicieron. Nuevamente apreciamos una diferencia estadísticamente significativa (p=0,0039) entre el grupo I y los grupos II y III, pero no (p=0,37) entre el grupo II y el III.La comparación de los niveles plasmáticos de antígeno p24 con la carga viral por PCR pone de manifiesto una gran disparidad de resultados. Conclusiones: El nivel plasmático del antígeno p24 es un buen marcador pronóstico de supervivencia y de progresión a SIDA o muerte en enfermos infectados por el VIH-1 y su validez se prolonga por lo menos 4 años. Una cifra aislada <20 pg/mL es un signo de mejor pronóstico. No parece existir paralelismo entre los valores plasmáticos de antígeno p24 y la carga viral (AU)

[Survival and disease progression in 251 patients with HIV-1 infection. Study of p24 antigen and viral burden as prognosis makers. Their value at 4 years of follow-up]. / Supervivencia y progresión de la enfermedad en 251 pacientes con infección por el VIH-1. Estudio del antígeno p24 y de la carga viral como marcadores pronóstico. Su valor a los 4 años de seguimiento.

BACKGROUND: Prospective study of survival and AIDS or death progression in a cohort of 251 HIV infected patients whose seroconversion time is unknown, with a main objective: To analyse p24 antigen plasmatic levels and viral load as surrogate markers. PATIENTS: 251 patients were included, most of them undergoing antiretroviral therapy, and were followed-up consecutively in the HIV/AIDS Unity of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova in Lleida. METHODS: We made clinical and analytical baseline studies and every 3 months thereafter. Related to p24 antigen 3 group were established: group I, < 20 pg/mL, group 2, 20-39 pg/mL, group 3, 40 or more pg/mL. We studied survival and progression according to baseline levels over 4 year period. Regard to viral load, we just compared this with p24 antigen in the last phase of the study (third and fourth year) for technical reasons. Survival analysis was made by Kaplan-Meier estimation. Relative risk was calculated by Cox's proportional hazards model. RESULTS: During the 48 months of follow-up 55 patients died. AIDS progression risk or death was 4.8 times higher for the p24 antigen > = 40 pg/mL group than for the p24 antigen < 20 pg/mL one; the relative risk of patients with p24 antigen between 20-39 pg/mL was 2.5 times higher than those included in the group of p24 antigen < 20 pg/mL. Related to progression study, 34 patients progressed. AIDS progression risk or death for p24 antigen > = 40 pg/mL group was 7.69 times higher compared with group 2 (p24 antigen levels between 20-39 pg/mL). The comparison with viral load by PCR determination shows controversial results. CONCLUSIONS: p24 antigen plasma level is a good survival and AIDS progress or death surrogate markers in HIV infected patients, and it is useful for 4 years or more. An isolated value < 20 pg/mL is a sign of good prognosis. Parallelism between p24 antigen plasmatic level and viral load has not been observed.

[The prognostic markers of survival and progression in HIV-1 infection. A study of CD4+ lymphocytes, antigen p24 and viral load during 3 years in a cohort of 251 patients]. / Marcadores pronóstico de supervivencia y de progresión en la infección por el VIH-1. Estudio de linfocitos CD4+, antígeno p24 y carga viral durante 3 años en una cohorte de 251 pacientes.

BACKGROUND: Prospective study of survival and AIDS or death progression in a cohort of 251 HIV infected patients whose seroconversion time is unknown, with 1 main objective: To analyse CD4+ lymphocytes count, p24 antigen plasmatic levels and viral load as surrogate markers. PATIENTS AND METHODS: 251 patients were included, most of them undergoing antiretroviral therapy, followed consecutively in the HIV/AIDS Unity of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova in Lleida. We made clinical and analytical baseline studies and every 3 months thereafter. In relation to CD4+ lymphocytes, 3 groups were established: group I, 500 or more cells/mL; group II, 200-499 cells/mL and group III, < 200 cells/mL. In the same way, with p24 antigen we established 3 group: group I, < 20 pg/mL, group II, 20-39 pg/mL, group III 40 or more pg/mL. We studied survival in relation to baseline levels and stability, the latter being understood as persistent levels in the initial group, or better, over 3 year period. Survival analysis was made by Kaplan-Meier estimation. Relative risk was calculated by Cox's proportional hazards model. RESULTS: During the 36 months of follow-up 53 patients died. AIDS progression risk or death was 4.8 times higher for the p24 antigen > = 40 pg/mL group than for the p24 antigen < 20 pg/mL one; patients with p24 antigen between 20-39 pg/mL relative risk was 2.5 times higher than those included in p24 antigen < 20 pg/mL group. These results emphasize that if we take into account the p24 antigen stability during these 36 months. In relation to progression study, 36 patients progressed. AIDS progression risk or death for p24 antigen > = 40 pg/mL group was 7.69 times higher in relation to that with p24 antigen levels between 20-39 pg/mL. The bivariable study shows that CD4 lymphocytes counts and p24 antigen level have quite an independent value. The comparison with viral load by PCR determination makes manifest discrepancy, difficult to explain. CONCLUSIONS: p24 antigen plasma level is a good survival and AIDS progress or death surrogate markers in HIV infected patients, and it is useful for 3 years or more. An isolated value < 20 pg/mL and, furthermore, the stability in successive controls under this concentration is a sign of good prognosis. Its value is emphasized with CD4+ lymphocytes count. It seem necessary that more comparative studies with viral load are required.

Marcadores pronóstico de supervivencia y de progresión en la infección por el VIH-1. Estudio de linfocitos CD4+, antígeno p24 y carga viral durante 3 años en una cohorte de 251 pacientes / Surrogate markers of survival and progression in HIV infection: study of CD4+ lymphocytes count, P24 gen and viral load in a cohort of 251 patients during 3 years

Fundamento: Analizar el valor del recuento de linfocitos CD4+, los niveles plasmáticos de antígeno p24 y la carga viral (RNA, PCR), como marcadores pronóstico en una cohorte de pacientes infectados por el VIH-1, cuyo tiempo de seroconversión es desconocido. Pacientes y métodos: Se incluyeron 251 pacientes, la mayoría con terapia antirretroviral, que fueron asistidos de forma consecutiva en la Unidad VIH/SIDA del Servicio de Medicina Interna del Hospital Universitario Arnau de Vilanova de Lleida. Se hicieron estudios clínico-analíticos en el momento de inclusión (basal) y luego, cada 3 meses. En relación con los linfocitos CD4+, se establecieron 3 grupos: Grupo I, 500 ó más células/ml; grupo II, 200-499 células/ml; grupo III, 40 pg/ml fue 4,8 veces mayor que para el grupo con antígeno 40 pg/ml fue 7,69 veces superior en relación al grupo con antígeno p24 < 20 pg/ml y 6 veces superior que el grupo con antígeno p24 entre 20 y 39 pg/ml. El estudio bivariable muestra cierta independencia entre la cifra de linfocitos CD4+ y el valor del antígeno p24. La comparación con la determinación de carga viral por PCR pone de manifiesto una discrepancia de difícil explicación. Conclusiones: El nivel plasmático del antígeno p24 es un buen marcador pronóstico de supervivencia y de progresión a SIDA o muerte en enfermos infectados por el VIH-1 y su validez se prolonga por lo menos 3 años (AU)

[The prognostic markers of HIV infection progression. A study of the p24 antigen in a cohort of 251 patients]. / Marcadores pronóstico de progresión en la infección por VIH. Estudio del antígeno p24 en una cohorte de 251 pacientes.

BACKGROUND: Prospective study of AIDS or death progression in a cohort of 251 HIV infected patients whose time of seroconversion is unknown, with 2 main objectives: 1. To analyse plasma level p24 antigen as a marker of progression. 2. To evaluate stability of plasma levels of p24 antigen as a marker of progression. PATIENTS AND METHODS: 251 patients were studied, most on antiretroviral therapy, who were attended at HIV/AIDS Unit of Internal Medicine Service of the Hospital Universitario Arnau de Vilanova de Lleida. Mean initial CD4 cell count were 376 x 10(6)/L (range: 0.8-1350) 51 cases had been diagnosed previously with AIDS, their were therefore excluded. Analysis of survival, according to initial plasma p24 antigen and Cd4 cell count as well as the stability of plasma level p24 antigen was performed by Kaplan-Meier test. Relative risk were calculate by Cox's proportional hazard model. RESULTS: During a follow-up period of 24 months, 38 patients progressed to AIDS or died. Relative risk (RR) of progression to AIDS or death related to the group with p24 antigen < 40 pg/ml was 5.48 when p24 antigen => 40 pg/ml (p < 0.0005). Relative risk of progression to AIDS or death for the patients with unstable plasmatic level of p24 antigen related to the group with stable plasmatic level was 4.25 (p < 0.0005). CONCLUSIONS: Plasma level and stability of p24 antigen are useful as a markers of risk of AIDS progression or death and they behaves as an independent prognostic markers in our patients. p24 antigen < 40 pg/ml is associated with a better prognosis.

Marcadores pronóstico de progresión en la infección por VIH.Estudio del antígeno p24 en una cohorte de 251 pacientes / Surrogate markers of progression in HIV infection: study of P24 antigen in a cohort of 252 patients

Fundamento: Estudio prospectivo de la progresión a SIDA o muerte en una cohorte de 251 pacientes infectados por el VIH, cuyo tiempo de seroconversión es desconocido, con dos objetivos primordiales: 1º. Analizar los niveles plasmáticos del antígeno p24 como marcador de progresión 2º. Valorar la estabilidad de los niveles plasmáticos del antígeno p24 como marcador de progresión. Pacientes y métodos: Se incluyeron inicialmente 251 pacientes, la mayoría con terapia antirretroviral, que fueron asistidos de forma consecutiva en la Unidad VIH/SIDA del Servicio de Medicina Interna del Hospital Universitario Arnau de Vilanova de Lleida. La media del recuento inicial de linfocitos CD4 fue de 376,283 x 106/L (rango 1,5 - 1350). 51 casos habían sido diagnosticados previamente de SIDA, por lo que fueron excluidos del estudio de progresión. Las comparaciones de las curvas de supervivencia, de acuerdo con las cifras iniciales de antígeno p24 y de linfocitos CD4, así como con la estabilidad o no de la antigenemia, se realizaron con la prueba de Kaplan-Meier. El cálculo del riesgo relativo se realizó mediante el modelo de riesgo proporcional de Cox. Resultados: Durante los 24 meses de seguimiento progresaron a SIDA o fallecieron 38 pacientes. El riesgo de progresión a SIDA o muerte para el grupo con antígeno p24 = ó > 40 pg / ml fue 5,48 veces superior al grupo con antígeno p24 < 40 pg/ml (p<0,0005). El riesgo de progresión a SIDA o muerte para el grupo con antígeno p24 inestable fue 4,25 veces superior al grupo con antígeno p24 estable (p<0,0005). Conclusiones: El nivel de antigenemia p24 y su estabilidad son unos buenos marcadores del riesgo de progresión a SIDA o muerte y se comporta como un factor pronóstico independiente en nuestro grupo de pacientes. Una cifra < 40 pg/ml aislada o mantenida se asocia con un mejor pronóstico (AU)

[Value of quantification of p24 antigen in plasma as a prognostic marker of survival in a cohort of 251 HIV-positive patients]. / Valor de la cuantificacion plasmática del antígeno p24 como marcador pronóstico de supervivencia en una cohorte de 251 pacientes VIH +.

OBJECTIVE: To analyse plasma p24 antigen as a marker of survival in a cohort of HIV-infected patients whose time of seroconversion is unknown. DESIGN: Prospective cohort study. SETTING: AIDS Unit in a teaching hospital. PATIENTS: 251 patients were studied, most on antiretroviral therapy. Mean initial CD4 cell counts were 376 x 106/ 1 (range: 0.8-1350). 51 cases had been diagnosed previously with AIDS. METHODS: Analysis of survival, according to initial plasma p24 antigen was performed by Kaplan-Meier test. Relative risks were calculated by Cox's proportional hazards model. RESULTS: During a follow-up period of 24 months, 46 patients died. Relative risk (RR) of death related to the group with p24 antigen = < 40 pg/ml was 3.32 when p24 antigen > 40 pg/ml (p = 0.0001). CD4+ cell levels adjusting, the result was 2.47 (CI 95% 1.37-4.46) (p = 0.0027). CONCLUSIONS: Plasma levels of p24 antigen is useful as a marker of the risk of death and it behaves as a independent prognostic marker in our patients. P24 antigen = < 40 pg/ml is associated with a better prognosis.