Performance of risk scores in predicting mortality at 3, 6, and 12 months in patients diagnosed with community-acquired pneumonia.

BACKGROUND: Risk scores (RS) evaluate the likelihood of short-term mortality in patients diagnosed with community-acquired pneumonia (CAP). However, there is a scarcity of evidence to determine the risk of long-term mortality. This article aims to compare the effectiveness of 16 scores in predicting mortality at three, six, and twelve months in adult patients with CAP. METHODS: A retrospective cohort study on individuals diagnosed with CAP was conducted across two hospitals in Colombia. Receiver Operating Characteristic (ROC) curves were constructed at 3, 6, and 12 months to assess the predictive ability of death for the following scoring systems: CURB-65, CRB-65, SCAP, CORB, ADROP, NEWS, Pneumonia Shock, REA-ICU, PSI, SMART-COP, SMRT-CO, SOAR, qSOFA, SIRS, CAPSI, and Charlson Comorbidity Index (CCI). RESULTS: A total of 3688 patients were included in the final analysis. Mortality at 3, 6, and 12 months was 5.2%, 8.3%, and 16.3% respectively. At 3 months, PSI, CCI, and CRB-65 scores showed ROC curves of 0.74 (95% CI: 0.71-0.77), 0.71 (95% CI: 0.67-0.74), and 0.70 (95% CI: 0.66-0.74). At 6 months, PSI and CCI scores showed performances of 0.74 (95% CI: 0.72-0.77) and 0.72 (95% CI: 0.69-0.74), respectively. Finally at 12 months, all evaluated scores showed poor discriminatory capacity, including PSI, which decreased from acceptable to poor with an ROC curve of 0.64 (95% CI: 0.61-0.66). CONCLUSION: When predicting mortality in patients with CAP, at 3 months, PSI, CCI, and CRB-65 showed acceptable predictive performances. At 6 months, only PSI and CCI maintained acceptable levels of accuracy. For the 12-month period, all evaluated scores exhibited very limited discriminatory ability, ranging from poor to almost negligible.

Predicciones de la entropía proporcional en la dinámica cardíaca / Predictions of proportional entropy in cardiac dynamics / Previsões de entropia proporcional na dinâmica cardíaca

Antecedentes: A partir de la teoría de sistemas dinámicos se desarrolló una metodología que permite diferenciar dinámicas cardíacas normales, en distintos niveles de enfermedad y en evolución entre estos estados. Esto se hizo cuantificando en el espacio de fases, mediante la entropía y sus proporciones, la probabilidad de parejas ordenadas de frecuencias cardiacas. Objetivo: Aplicar clínicamente la metodología desarrollada a 400 dinámicas cardíacas para establecer su efectividad comparándola con el diagnóstico clínico convencional. Método: Se tomaron Holters de 400 individuos; 50 diagnosticados como normales y 350 con diferentes patologías. Para cada uno se construyó un atractor en el mapa de retardo y se evaluó, mediante la entropía y sus proporciones, la probabilidad de ocupación de pares ordenados de frecuencias cardíacas durante 18 horas. Se compararon las medidas obtenidas con los valores de normalidad y enfermedad establecidos previamente para obtener el diagnóstico de cada Holter. Las conclusiones del Holter y los antecedentes clínicos sólo fueron desenmascarados luego de haber aplicado la metodología físico-matemática para calcular sensibilidad, especificidad y coeficiente Kappa respecto al Gold-Estándar. Resultados: con las proporciones de la entropía de los atractores se diferenciaron dinámicas cardíacas agudas, crónicas, normales, y evolución normalidad-enfermedad. Se confirmó la aplicabilidad clínica de la metodología predictiva desarrollada para el Holter, que mostró una sensibilidad y especificidad del 100%. La concordancia entre el Gold-Estándar y el diagnóstico físicomatemático fue 1. Conclusiones: La aplicación de la metodología permitió establecer cuantitativamente estados de normalidad y enfermedad de la dinámica cardíaca, evidenciando una auto-organización del atractor dinámico geométrico que constituye un método de ayuda diagnóstica aplicable a la clínica.

Based on dynamic systems theory, a methodology that allows to differentiate normal cardiac dynamics, different levels of abnormality and evolution between these states, was developed. This was done by quantifying the probability of ordered pairs of heart rates in the phase space, through entropy and its proportions. To apply in a clinical setting the developed methodology to 400 cardiac dynamics in order to establish its effectiveness by comparing it with the conventional diagnosis. Holters from 400 individuals were tested for a minimum of 18 hours; 50 with normal diagnosis and 350 with different pathologies. An attractor was built for each one of them in the delay map, and the occupation probability of ordered pairs of heart rates was evaluated through entropy and its proportions. Afterwards, results were compared with values of normality and disease previously established to obtain the diagnosis for each Holter. The findings of Holter and medical history were only revealed after applying the physical-mathematical methodology, in order to calculate sensitivity, specificity and Kappa coefficient regarding to the Gold-Standard. With the entropy proportions of the attractors, acute cardiac dynamics were differentiated from chronic and normal ones, as well as the evolution between normality and disease. A clinical application of the predictive methodology for Holter was developed. Sensitivity and specificity were both 100% and the correlation between the Gold-Standard and the physical-mathematical diagnosis was 1. The application of the methodology allowed establishing quantitatively states of normality and disease of the cardiac dynamic, showing a self-organization of the geometrical dynamic attractor.

Antecedentes: A partir da teoria de sistemas dinâmicos se desarrolho uma metodologia que permite diferenciar dinâmicas cardíacas normais, em distintos niveles de doença e na evolução entre estes estados, o qual foi realizado quantificando no espaço de fases a probabilidade de pares ordenados de frequências cardíacas, através da entropia e as suas proporções. Objetivo: Aplicar clinicamente a metodologia desenvolvida a 400 dinâmicas cardíacas para estabelecer sua eficácia comparada com o diagnóstico clínico convencional. Método: Se tiraram Holters de 400 pessoas, 50 deles foram diagnosticados como normais e 350 têm diferentes patologias. Um atractor no mapa de retardos foi construído para cada um deles e, através da entropia e as suas proporções, a probabilidades de ocupação de pares ordenados de frequências cardíacas durante 18 horas foi avaliada. Além disso, as medidas obtidas foram comparadas com os valores de normalidade e doenças estabelecidas previamente para obter o diagnostico de cada Holter. As conclusões do Holter e os antecedentes clínicos somente foram descobertos logo de aplicar a metodologia físico-matemática para calcular a sensibilidade, especificidade y coeficiente Kappa acerca do Padrão-Ouro (Gold-Standard). Resultados: As dinâmicas cardíacas agudas, crônicas, normais y a evolução da normalidade e as doenças foram diferenciadas pelas proporções da entropia dos atractores. Confirmou-se a aplicabilidade clínica da metodologia preditiva desenvolvida para o Holter, a qual demonstrou uma sensibilidade e especificidade de 100%. O acordo entre o Padrão-Ouro (Gold-Standard) e o diagnóstico físico-matemático foi 1. Conclusões: A aplicabilidade da metodologia permitiu estabelecer quantitativamente estado de normalidade e doenças da dinâmica cardíaca, mostrando uma auto-organização do atrator dinâmico geométrico que constitui um método de ajuda diagnostica aplicável à clínica.

"Not Unless It's a Life or Death Thing": A Qualitative Study of the Health Care Experiences of Adults Who Stutter.

BACKGROUND: For adults who stutter, communication difficulties can impact many spheres of life. Previous studies have not examined how stuttering might impact patient's experiences with the medical system. OBJECTIVE: Our objective was to understand the range and depth of experiences with the medical system among adults who stutter. DESIGN: This was a qualitative study using age-stratified focus groups. PARTICIPANTS: Sixteen adults who stutter were recruited at a national conference about stuttering. APPROACH: We conducted three focus groups. Participants also completed a written questionnaire about sociodemographic characteristics, health status, and the impact of stuttering on their life [using the St. Louis Inventory of Life Perspectives Scale (SL-ILP-S) Total Effect Score]. We analyzed data using an iterative, thematic analysis, with an inductive approach, at a semantic level. KEY RESULTS: Participants were mostly (75 %) male and resided throughout the United States. The mean SL-ILP-S Total Effect Score was 27.3, indicating that stuttering caused minimal concern in participants' lives. Despite this, we identified five themes that characterize ways in which stuttering affects interactions with the medical system. Participants described (1) discomfort speaking with office staff and physicians, which resulted in (2) avoiding health care interactions because of stuttering, and (3) relying on a third party to navigate the medical system. During visits with physicians, participants felt that (4) discussing stuttering with physicians required trust and rapport, and (5) speaking assertively with physicians required self-acceptance of their stuttering. CONCLUSIONS: We identified ways in which stuttering affects medical interactions. These results highlight the need for increased awareness and training for medical staff and physicians when caring for persons who stutter. Future studies among diverse samples of stutterers can determine the effects of stuttering on medical interactions, and inform the development of interventions to provide high quality health care for adults who stutter.

Access to HIV/AIDS care: a systematic review of socio-cultural determinants in low and high income countries.

BACKGROUND: The role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies. METHODS: Ten electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries. RESULTS: Thirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment. CONCLUSIONS: This review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.