Adaptation of antibiotic treatment to clinical practice guidelines in patients aged ⩾65 years hospitalised due to community-acquired pneumonia.

Early, conforming antibiotic treatment in elderly patients hospitalised for community-acquired pneumonia (CAP) is a key factor in the prognosis and mortality. The objective was to examine whether empirical antibiotic treatment was conforming according to the Spanish Society of Pulmonology and Thoracic Surgery guidelines in these patients. Multicentre study in patients aged ⩾65 years hospitalised due to CAP in the 2013-14 and 2014-15 influenza seasons. We collected socio-demographic information, comorbidities, influenza/pneumococcal vaccination history and antibiotics administered using a questionnaire and medical records. Bivariate analyses and multilevel logistic regression were made. In total, 1857 hospitalised patients were included, 82 of whom required intensive care unit (ICU) admission. Treatment was conforming in 51.4% (95% confidence interval (CI) 49.1-53.8%) of patients without ICU admission and was associated with absence of renal failure without haemodialysis (odds ratio (OR) 1.49, 95% CI 1.15-1.95) and no cognitive dysfunction (OR 1.71, 95% CI 1.25-2.35), when the effect of the autonomous community was controlled for. In patients with ICU admission, treatment was conforming in 45.1% (95% CI 34.1-56.1%) of patients and was associated with the hospital visits in the last year (<3 vs. ⩾3, OR 2.70, 95% CI 1.03-7.12) and there was some evidence that this was associated with season. Although the reference guidelines are national, wide variability between autonomous communities was found. In patients hospitalised due to CAP, health services should guarantee the administration of antibiotics in a consensual manner that is conforming according to clinical practice guidelines.

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.

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.

Validation of a predictive rule for the management of community-acquired pneumonia.

The CURB-65 score (Confusion, Urea > 7 mmol x L(-1), Respiratory rate > or = 30 x min(-1), low Blood pressure, and age > or = 65 yrs) has been proposed as a tool for augmenting clinical judgement for stratifying patients with community-acquired pneumonia (CAP) into different management groups. The six-point CURB-65 score was retrospectively applied in a prospective, consecutive cohort of adult patients with a diagnosis of CAP seen in the emergency department of a 400-bed teaching hospital from March 1, 2000 to February 29, 2004. A total of 1,100 inpatients and 676 outpatients were included. The 30-day mortality rate in the entire cohort increased directly with increasing CURB-65 score: 0, 1.1, 7.6, 21, 41.9 and 60% for CURB-65 scores of 0, 1, 2, 3, 4, and 5, respectively. The score was also significantly associated with the need for mechanical ventilation and rate of hospital admission in the entire cohort, and with duration of hospital stay among inpatients. The CURB-65 score (Confusion, Urea > 7 mmol x L(-1), Respiratory rate > or = 30 x min(-1), low Blood pressure, and age > or = 65 yrs), and a simpler CRB-65 score that omits the blood urea measurement, helps classify patients with community-acquired pneumonia into different groups according to the mortality risk and significantly correlates with community-acquired pneumonia management key points. The new score can also be used as a severity adjustment measure.

Gradiente venoarterial de anhídrido carbónico: valor pronóstico y relaciones con el índice cardíaco en pacientes críticos / Carbon anhydride arterial vein gradient: prognosis value and relationships with heart rate in critical patients

En 64 pacientes (P) se midió dentro de las 6 horas de la admisión, el gradiente venoarterial de CO2 (Gv-aCO2) (G) diferenciando 2 grupos A (G < a 6 mmHg) y B (> 6 mmHg) evaluándose en ellos el desarrollo de fallas múltiples (FM) y la mortalidad (M). En 35 P se midió concomitantemente el G y el índice cardíaco (IC) en 50 oportunidades correlacionándose sus valores; a la vez se midió en ellos el pHi. El desarrollo de FM y la M fueron significativamente mayores en el grupo B; la correlación entre G e IC fue débil, los niveles de IC y G en estos P definieron 4 grupos de determinaciones: I: IC < 2,7, G > 6; II: IC < 2,7, G ? 6; III: IC > 2,7, G ? a 6 y IV: IC > 2,7, G > 6 (en el último no se ubicaron mediciones). En I la X ñ DE fue significativamente menor que II y en este último que en III. El G puede ser de utilidad para establecer pronóstico en la admisión. El más reducido pHi en las determinaciones del grupo I evidencia las consecuencias de la caída efectiva del volumen circulante sumado a alteraciones en la regulación del microflujo en relación al II en el cual esas últimas estarían ausentes (similar IC con G normal)

Gradiente venoarterial de anhídrido carbónico: valor pronóstico y relaciones con el índice cardíaco en pacientes críticos / Carbon anhydride arterial vein gradient: prognosis value and relationships with heart rate in critical patients

En 64 pacientes (P) se midió dentro de las 6 horas de la admisión, el gradiente venoarterial de CO2 (Gv-aCO2) (G) diferenciando 2 grupos A (G < a 6 mmHg) y B (> 6 mmHg) evaluándose en ellos el desarrollo de fallas múltiples (FM) y la mortalidad (M). En 35 P se midió concomitantemente el G y el índice cardíaco (IC) en 50 oportunidades correlacionándose sus valores; a la vez se midió en ellos el pHi. El desarrollo de FM y la M fueron significativamente mayores en el grupo B; la correlación entre G e IC fue débil, los niveles de IC y G en estos P definieron 4 grupos de determinaciones: I: IC < 2,7, G > 6; II: IC < 2,7, G ? 6; III: IC > 2,7, G ? a 6 y IV: IC > 2,7, G > 6 (en el último no se ubicaron mediciones). En I la X ñ DE fue significativamente menor que II y en este último que en III. El G puede ser de utilidad para establecer pronóstico en la admisión. El más reducido pHi en las determinaciones del grupo I evidencia las consecuencias de la caída efectiva del volumen circulante sumado a alteraciones en la regulación del microflujo en relación al II en el cual esas últimas estarían ausentes (similar IC con G normal) (AU)

Postoperative intra-abdominal sepsis requiring reoperation. Value of a predictive index.

In this study we analyze the results of the use of a predictive index to decide whether to perform abdominal reoperation in the event of septic complications. During a 5-year period, a population of 542 critically ill patients received major abdominal surgery. Patients were divided into two groups: (1) the control group, for which the decision to reoperate was made routinely, based on clinical consensus of the medical team; and (2) the Abdominal Reoperation Predictive Index group, for which the decision to reoperate was made with the help of a mathematical index involving eight mainly clinical variables. The use of Abdominal Reoperation Predictive Index enabled mortality among patients undergoing reoperation to be lowered, the time elapsing between the first operation and relaparotomy to be reduced, and the length of stay in the intensive care unit to be shortened. We conclude that the systematic application of an index, without disregarding clinical judgment, allows the quality of attention to be improved, cost to be lowered, and the level of conflicts generated by the difficult decision to perform reoperation to be curtailed.

Gastric mucosal pH as a prognostic index of mortality in critically ill patients.

OBJECTIVE: To determine if measurements of gastric intramucosal pH have prognostic implications regarding ICU mortality. DESIGN: Prospective comparison of outcome. SETTING: General adult ICUs in two teaching hospitals. PATIENTS: Eighty consecutive patients age 18 to 84 yrs (mean 63.4), 50 men and 30 women, 55% in the medical and 45% in the surgical services. METHODS: Gastric intramucosal pH was measured on ICU admission and again 12 hrs later. A value of greater than or equal to 7.35 was used to differentiate between normal and low gastric intramucosal pH. MEASUREMENTS AND MAIN RESULTS: Fifty-four patients had a normal gastric intramucosal pH and 26 patients had a low gastric intramucosal pH on ICU admission. The mortality rate was greater in the low gastric intramucosal pH group (65.4% vs. 43.6%; p less than .04). The frequency of sepsis and the presence of multisystem organ failure also were greater in the low gastric intramucosal pH group (p less than .01). Further stratification of patients according to gastric intramucosal pH measured 12 hrs after admission showed a greater mortality rate in patients with persistently low gastric intramucosal pH when compared with patients with normal gastric intramucosal pH during the first 12 hrs (86.7% vs. 26.8%; p less than .001). CONCLUSIONS: Measurements of gastric intramucosal pH on ICU admission, and again 12 hrs later, have a high specificity for predicting patient survival in this ICU patient population (77.8% to 80.6%). Furthermore, given its relative noninvasive nature, tonometrically measured gastric intramucosal pH may be a useful addition to patient monitoring in the ICU.