http://academic.oup.com/milmed/article-pdf/146/7/506/24126715/milmed-146-7-506.pdf

Goodman and Gilman's The Pharmacological Basis of Therapeutics

A versatile loop-mediated isothermal amplification microchip platform for Streptococcus pneumoniae and Mycoplasma pneumoniae testing at the point of care

Community-acquired pneumonia (CAP) can occur at any time of life, but its incidence and risk of death are linked to increasing age. CAP in the elderly is a major health problem associated with high rates of readmission, morbidity, and mortality. Since the clinical presentation of pneumonia in the elderly may be atypical, clinicians should suspect pneumonia in older patients presenting symptoms such as falls and altered mental status, fatigue, lethargy, delirium, anorexia, in order to avoid the complications associated with delayed diagnosis and therapy. Streptococcus pneumoniae remains the most frequently reported pathogen in this population. However, particular attention should be paid to patients with risk factors for multidrug resistant pathogens, because a large proportion of elderly persons present multimorbidity. Vaccination is one of the most important preventive approaches for CAP in the elderly. In addition, lifestyle-tailored interventions for different modifiable risk factors will help to reduce the risk of pneumonia in elderly persons. Surveillance of etiological pathogens may improve vaccination policies in this population.

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Characteristics and Management of Community-Acquired Pneumonia in the Era of Global Aging

Very old (aged ≥80 years) adults constitute an increasing proportion of the global population. Currently, this subgroup of patients represents an important percentage of patients admitted to the intensive care unit. Community-acquired pneumonia (CAP) frequently affects very old adults. However, there are no specific recommendations for the management of critically ill very old CAP patients. Multiple morbidities, polypharmacy, immunosenescence and frailty contribute to an increased risk of pneumonia in this population. CAP in critically ill very old patients is associated with higher short- and long-term mortality; however, because of its uncommon presentation, diagnosis can be very difficult. Management of critically ill very old CAP patients should be guided by their baseline characteristics, clinical presentation and risk factors for multidrug-resistant pathogens. Hospitalisation in intermediate care may be a good option for critical ill very old CAP patients who do not require invasive procedures and for whom intensive care is questionable in terms of benefit.

https://err.ersjournals.com/content/errev/29/155/190126.full.pdf

Community-acquired pneumonia in critically ill very old patients: a growing problem.

Detailed, nationally representative data describing high-risk populations and circumstances involved in antibiotic adverse events (AEs) can inform approaches to prevention. Describe US burden, rates, and characteristics of emergency department (ED) visits by adults for antibiotic AEs. Nationally representative, public health surveillance of adverse drug events (National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance [NEISS-CADES]) and a nationally projected database of dispensed prescriptions (QuintilesIMS), 2011–2015. Antibiotic-treated adults (≥ 20 years) seeking ED care. Estimated annual numbers and rates of ED visits for antibiotic AEs among outpatients treated with systemically administered antibiotics. Based on 10,225 cases, US adults aged ≥ 20 years made an estimated 145,490 (95% confidence interval, 115,279–175,701) ED visits for antibiotic AEs each year in 2011–2015. Antibiotics were implicated in 13.7% (12.3–15.2%) of all estimated adult ED visits for adverse drug events. Most (56.6%; 54.8–58.4%) antibiotic AE visits involved adults aged < 50 years, and 71.8% (70.4–73.1%) involved females. Accounting for prescriptions dispensed from retail and long-term care pharmacies, adults aged 20–34 years had twice the estimated rate of ED visits for oral antibiotic AEs compared with those aged ≥ 65 years (9.7 [7.6–11.8] versus 4.6 [3.6–5.7] visits per 10,000 dispensed prescriptions, respectively). Allergic reactions accounted for three quarters (74.3%; 70.0–78.6%) of estimated ED visits for antibiotic AEs. The three most frequently implicated antibiotic classes in ED visits for antibiotic AEs were oral sulfonamides (23.2%; 20.6–25.8%), penicillins (20.8%; 19.3–22.4%), and quinolones (15.7%; 14.2–17.1%). Per-prescription rates declined with increasing age group. Antibiotics are a common cause of ED visits by adults for adverse drug events and represent an important safety issue. Quantifying risks of AEs from specific antibiotics for specific patient populations, such as younger adults, provides additional information to help clinicians assess risks versus benefits when making the decision to prescribe or not prescribe an antibiotic. AE rates may also facilitate communication with patients about antibiotic risks.

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National Estimates of Emergency Department Visits for Antibiotic Adverse Events Among Adults-United States, 2011-2015.

Community-acquired pneumonia (CAP) is an increasing problem in the elderly that is associated with elevated morbidity and mortality. Given the expected increased life expectancy, this problem is only likely to worsen, so it has been considered that treatment effects must be examined separately in elderly adults with CAP. Areas covered: In this narrative review, we give an update of the available data of antibiotics for elderly patients with CAP. Clinical features, drug pharmacokinetics and pharmacodynamics, adverse effects, and outcomes differ in CAP depending on patient age. Older age, for example, can affect the effect of specific antibiotic regimens on important CAP clinical outcomes. Current guidelines do not offer specific recommendations for the management of CAP in elderly patients. Expert opinion: Most of our knowledge about the treatment of CAP in elderly patients has been gained from studies in young populations. However, elderly patients with CAP deserve special attention because there are several factors in this population that could influence their response to antibiotic regimens in CAP.

Pharmacotherapy for community-acquired pneumonia in the elderly

Abstract Introduction: In the Emergency Department (ED), a thorough cardiovascular evaluation cannot be accomplished only with physical examination. E-Point Septal Separation (EPSS) measure through Point-of-Care Ultrasound (POCUS) has been used to evaluate systolic function in echocardiography. We analyzed EPSS for diagnosis of Left Ventricle Ejection Fraction <50% and ≤40% in ED patients. Methods: Retrospective analysis of a convenience sample of patients presenting to ED with chest pain or dyspnea who underwent admission POCUS evaluation by Internal Medicine Specialist unaware of Transthoracic Echocardiogram. Accuracy was assessed with sensitivity, specificity, likelihood ratios (LR) and Receiver operating characteristics (ROC) curve. The best cut off point was calculated using Youden Index. Results: Ninety-six patients were included. Median EPSS and LVEF were 10mm and 41% respectively. Area Under the ROC Curve (AUC-ROC) to diagnose a LVEF <50% was 0.90 (IC95% 0.84-0.97). Youden Index was 0.71 with cut off point EPSS at 9.5mm, performing with a sensitivity of 0.80, a specificity of 0.91, a positive LR of 9.8 and a negative LR of 0.2. AUC-ROC to diagnose a LVEF ≤40% was 0.91 (IC95% 0.85-0.97). Youden Index was 0.71 with a cut off point EPSS at 9.5mm, performing with a sensitivity of 0.91 and specificity of 0.80, a positive LR of 4.7 and a negative LR of 0.1. Conclusion: EPSS can reliably diagnose reduced LVEF in a set of ED patients with cardiovascular symptoms. A cut off point at 9.5 mm has good sensitivity, specificity and Likelihood ratios.

/pdf/e-point-septal-separation-accuracy-for-the-diagnosis-of-mild-2p2mw28a.pdf

E-Point Septal Separation Accuracy for the Diagnosis of Mild and Severe Reduced Ejection Fraction in Emergency Department Patients

Introduction Different factors are critical when assessing COVID-19 mortality, and can explain why severity differs so widely among populations. However, there is little information regarding prognostic factors and mortality in COVID-19 from Latin American countries. Objectives To determine prognostic factors in hospitalized COVID-19 patients and to evaluate the impact of tocilizumab use in patients with hyperinflammatory syndrome and severe disease defined by the National Early Warning Score 2 (NEWS2) with a value greater than or equal to seven points. Materials and methods This retrospective cohort study included hospitalized COVID-19 patients from May to July 2020. A multivariate logistic regression analysis was performed to determine independent factors associated with mortality. Results A total of 136 patients required hospital admission. In-hospital mortality was 39.7%. Mortality was observed to be potentiated by older age, LDH serum levels and the presence of type 2 diabetes mellitus. Lymphopenia and lower PaO2/FiO2 ratio were more common in these patients. Similarly, patients who died were classified more frequently with severe disease. The independent factors associated with in-hospital mortality were age greater than 65 years, type 2 diabetes mellitus, NEWS2 greater than or equal to seven points and LDH greater than 400U/L. The use of Tocilizumab alone was not related with decreased in-hospital mortality. Subgroup analysis performed in patients with hyperinflammation and severe disease showed similar results. Conclusions COVID-19 mortality in hospitalized patients was high and mainly related with older age, comorbidities, LDH and the severity of disease at hospital admission.

Prognostic Factors in Hospitalized COVID-19 Patients at the Start of the Pandemic in Colombia: A Retrospective Cohort Study

/pdf/association-of-inferior-vena-cava-diameter-in-the-emergency-1bqjokgl.pdf

Association of inferior vena cava diameter in the emergency room and early mortality in septic patients

Acute decompensated heart failure (ADHF) is one of the most frequent causes of emergency department (ED) visits. Point-of-Care Ultrasound (POCUS) is a reliable, easy-to-use, and available tool for an accurate diagnosis of ADHF. We aimed to analyze the impact of introducing POCUS as an additional tool to clinical standard diagnosis in clinical times of hospitalized heart failure patients.Retrospective cohort study comparing patients consulting to ED for heart failure acute decompensation previous to the rutinary use of POCUS versus patients who received an ultrasound-guided diagnosis at entrance. Ultrasound evaluation was additional to standard diagnosis (which included natriuretic peptides, images, etc). Cumulative incidence functions were calculated for time to treatment, time to disposition decision, and time to discharge. We used a flexible parametric model for estimate the time ratio (TR) in order to reflect the effect of POCUS.A total of 149 patients were included. The most frequent comorbid condition was hypertension (71.8%) followed by type 2 diabetes (36.2%). B type natriuretic peptide (BNP) was over 500 ng/ml. Most patients had Stevenson B profile (83.9%) at admission. In the cumulative incidence model (Fig. A), the TR (time ratio) for the outcome time to treatment was 1.539 (CI 95% 0.88 to 2.69). The TR for the outcome time to disposition decision was 0.665 (CI 95% 0.48 to 0.99). The TR for the outcome time to discharge (hospital length of stay) was 0.663 (CI 95% 0.49 to 0.90).In our study, the introduction of POCUS to ADHF patients decreases time to disposition decision and total length of hospital stay. Conversely, time to treatment augments. There is need for the evaluation of ultrasound as an intervention in clinical trials to confirm these findings. 

Jose A Nuñez-Ramos

Papers

Pharmacotherapy for community-acquired pneumonia in the elderly

E-Point Septal Separation Accuracy for the Diagnosis of Mild and Severe Reduced Ejection Fraction in Emergency Department Patients

Prognostic Factors in Hospitalized COVID-19 Patients at the Start of the Pandemic in Colombia: A Retrospective Cohort Study

Association of inferior vena cava diameter in the emergency room and early mortality in septic patients

Point of care ultrasound impact in acute heart failure hospitalization: A retrospective cohort study.