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Background The relationship between body mass index (BMI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) has not been fully investigated in patients with community-acquired pneumonia (CAP). Methods This prospective observational study examined 510 consecutive patients hospitalized for CAP. NT-proBNP, BMI, and the pneumonia severity index (PSI) were determined for all participants. The moderating effects of BMI on the relationship between NT-proBNP and CAP mortality were examined using interaction terms in a multivariable regression model. The ability of NT-proBNP to predict mortality was evaluated using the area under the curve (AUC). Results A significant inverse relationship was observed between BMI and NT-proBNP. After multivariable adjustment including BMI, NT-proBNP remained a significant predictor of CAP mortality. The AUC of the fully adjusted (including BMI) NT-proBNP model was significantly higher than that excluding BMI (p = 0.021) and that of PSI (p = 0.038), respectively. The predictive performance of NT-proBNP for mortality significantly differed by BMI group, with the NT-proBNP of the overweight and obesity group having a significantly higher AUC than that of the underweight and normal-weight group. The AUC of NT-proBNP was significantly higher and tended to be higher than that of PSI in the overweight group (p = 0.013) and the obesity group (p = 0.113), respectively. Conclusions BMI significantly strengthens the prognostic performance of NT-proBNP in CAP patients. The BMI-NT-proBNP interaction is significantly associated with CAP mortality, but as a prognostic determinant for CAP, NT-proBNP seems to be more useful for overweight and obese patients than for underweight and normal-weight patients., Author(s): Jong Seok Lee [sup.1] [sup.2] , Seok Hoon Ko [sup.3] , Jungyoup Lee [sup.4] , Ki Young Jeong [sup.1] [sup.2] Author Affiliations: (1) Department of Emergency Medicine, Kyung Hee [...]

Byline: Tankut Hakki Akay (1), Suleyman Ozkan (1), Bahadir Gultekin (1), Emrah Uguz (1), Birgul Varan (2), Atilla Sezgin (1), Kursad Tokel (2), Sait Aslamaci (1) Keywords: Phrenic nerve; Diaphragma paralysis; Diaphragma placation; Infant; Mortality Abstract: Diaphragmatic paralysis (DP) after cardiac surgery is an important complication especially in infants. We analyzed the incidence, clinical course, surgical management and follow up of the patients with DP, retrospectively. Between 1996 and 2005, 3,071 patients underwent cardiac surgery. Total number of patients with DP was 152 (4.9%). Out of 152 patients, 42 were surgically treated with transthoracic diaphragm plication (1.3%). The overall incidence of diaphragm paralysis was higher in correction of tetralogy of Fallot (31.5%), Blaloc--Taussig (B--T) shunt (11.1%) and VSD closure with pulmonary artery patch plasty (11.1). The incidence of DP which require plication was higher in B--T shunt (23.8%) arterial switch (19%) and correction of tetralogy of Fallot (11.9%). Mean and median age at the time of surgery were 17.8+-3.6 and 6 months, respectively. Median time from cardiac surgery to surgical plication was 12 days. Indications for plication were repeated reintubations (n=22), failure to wean from ventilator (n=12), recurrent lung infections (n=5) and persistent respiratory distress (n=3). Mortality rate was 19.1%. Being under 1 year of age, pneumonia and plication 10 days after mechanical ventilation were associated with higher incidence mortality (P Author Affiliation: (1) Department of Cardiovascular Surgery, Baskent University, 06552, Ankara, Turkey (2) Department of Pediatric Cardiology, Baskent University, 06552, Ankara, Turkey Article History: Registration Date: 13/02/2006 Accepted Date: 13/02/2006 Online Date: 04/03/2006

Byline: Jordi Valles (1), Eduard Mesalles (2), Dolors Mariscal (1), Ma Fernandez (1), Rocio Pena (1), Jose Luis Jimenez (2), Jordi Rello (3) Keywords: Pneumonia; Intensive care unit; Hospital-acquired infection Abstract: Objective To examine the characteristics, prognostic factors, and outcome of patients with severe hospital-acquired pneumonia admitted to the ICU. Design and setting Prospective observational clinical study in two medical-surgical ICUs with 16 and 20 beds Patients and participants During a 7-year period all hospitalized patients requiring admission to either ICU for hospital-acquired pneumonia were followed up. Measurements and results We diagnosed 96 episodes of severe hospital-acquired pneumonia, and in 67 cases a causal diagnosis was made. Most episodes were late-onset pneumonia. Gram-negative micro-organisms were isolated in 51% of episodes diagnosed, and Pseudomonas aeruginosa was the most frequent pathogen isolated (24%). Clearly significant variations happened between hospitals, particularly affecting the incidence of Aspergillus spp. and Legionella pneumophila. Forty-nine patients developed septic shock (51%). Fifty-one patients died (53%). Aspergillosis and pneumonia due to P. aeruginosa were associated with the highest mortality. Septic shock (OR: 14.27) and chronic obstructive pulmonary disease (OR: 6.11) were independently associated with a poor prognosis. Conclusions Patients with severe hospital-acquired pneumonia admitted to the ICU present high mortality. The presence of septic shock and chronic obstructive pulmonary disease in conjunction with specific microorganisms are associated with a poor prognosis. Local epidemiological data combined with a patient-based approach may allow a more accurate therapy decision making. Author Affiliation: (1) Critical Care Center, Hospital Sabadell, Institut Universitari Parc Tauli-Universitat Autonoma de Barcelona, Parc Tauli s/n, 08208, Barcelona, Spain (2) Intensive Care Department, Hospital Universitari Germans Trias i Pujol, Universitat Autonoma de Barcelona, Badalona. Barcelona, Spain (3) Critical Care Department, Hospital Universitari Joan XXIII, Universitat Rovira & Virgili, Tarragona, Spain Article History: Received Date: 18/10/2002 Accepted Date: 18/08/2003 Online Date: 10/09/2003

Byline: R. Raz (1), P. Dyachenko (2), Y. Levy (3), E. Flatau (4), N. Reichman (4) Abstract: Background: Understanding what determines the prognosis of community-acquired pneumonia (CAP) is especially important for decisions on hospitalization and antimicrobial therapy. The objective of the present study was to compare the predictability of mortality in our patients to that of the pneumonia patient outcomes research team (PORT) study. Patients and Methods: Data of 320 patients admitted with CAP were retrospectively evaluated and classified according to the published scheme. Results: One-month mortality was 14.4% 1-year mortality was 27.8%, two-thirds from new episodes. Univariate logistic regression risk factors for the 1-month mortality rate included leukocytosis, anemia, hypoalbuminemia, elevated blood urea nitrogen, aY= two comorbidities, tachycardia, tachypnea, acidosis, stupor, age &gt 65 years and high serum lactic dehydrogenase. These variables, except the last two, plus pleural effusion and bilateral infiltration were also risk factors for 1-year mortality. In the multivariate models, eight of these factors were significant risk factors, four for 1-month mortality and six for 1-year mortality. Our model for prediction of 1-month mortality had a sensitivity of 65%, specificity of 95% and accuracy of 91%. Conclusion: Agreement between predictions by our model and the published model was considerable, showing that most patients in the low score groups should not have been hospitalized. Author Affiliation: (1) Infectious Diseases unit, Ha'Emek Medical Cener, Afula 18101, and Rappaport School of Medicine, Technion, Haifa, Israel. raz_r@clalit.org.il, IL (2) Internal Medicine B, Ha'Emek Medical Center, Afula, Israel, IL (3) Internal Medicine A, Ha'Emek Medical Center and Rappaport School of Medicine, Technion, Haifa, Israel, IL (4) Internal Medicine B, Ha'Emek Medical Center and Rappaport School of Medicine, Technion, Haifa, Israel, IL Article note: Received: May 5, 2002 * Revision accepted: October 5, 2002 R. Raz (corresponding author)

Byline: A. Gacouin (1), Y. Le Tulzo (1), S. Lavoue (1), C. Camus (1), J. Hoff (1), R. Bassen (2), C. Arvieux (1), C. Heurtin (3), R. Thomas (1) Keywords: Legionella pneumophila Severe pneumonia Prognostic factors Intensive care Fluoroquinolones Erythromycin Spiramycin Abstract: Objective. To compare the outcome of patients with severe Legionella pneumonia (LP) according to the presence or absence of prognostic factors currently reported in the literature and delays in initiating fluoroquinolones and macrolides. Design. Retrospective clinical investigation. Setting. Intensive care unit (ICU) of an university hospital. Patients. Forty-three consecutive cases with no previous treatment with a macrolide or a fluoroquinolone. Measurements and main results. The 14 (33%) patients who died of LP were compared with the 29 survivors. Thirty-eight patients (88%) received a fluoroquinolone in combination with a macrolide agent, two patients erythromycin alone and three ofloxacin alone. In univariate analysis, SAPS II more than 46 (p=0.006) and intubation requirement (p=0.012) were associated with a higher mortality whereas the administration of fluoroquinolones (p=0.011) or erythromycin (p=0.044) within 8 h of arrival on the ICU was associated with better survival. By logistic regression analysis, SAPS II score more than 46 [odds ratio (OR) 8.69 95% confidence interval (CI) 1.15--66.7 p=0.036], duration of symptoms prior to ICU admission longer than 5 days (OR 7.46 95% CI 1.17--47.6) were independent risk factors for death. Fluoroquinolone administration within 8 h of ICU arrival (OR 0.16 95% CI 0.03--0.96 p=0.035) was associated with a reduced mortality. Conclusions. SAPS II score higher than 46, duration of symptoms prior to ICU admission longer than 5 days and intubation were associated with increased mortality. Initiation of fluoroquinolone therapy within 8 h of ICU admission significantly reduced mortality. Author Affiliation: (1) Service de Maladies Infectieuses et de Reanimation Medicale, Hopital Pontchaillou, Rue Henri Le Guilloux, 35033 Rennes Cedex, France (2) Service de Pneumologie, Hopital Pontchaillou, Rue Henri Le Guilloux, 35033 Rennes, France (3) Laboratoire de bacteriologie et de virologie. Hopital Pontchaillou, Rue Henri Le Guilloux, 35033 Rennes, France Article History: Received Date: 18/07/2001 Accepted Date: 07/03/2002 Article note: Electronic Publication

Byline: J. Hedlund (1), L.-O. Hansson (2) Keywords: Key words Pneumonia; Procalcitonin; C-reactive protein; Etiology; Prognosis Abstract: Background: The diagnostic value of admission serum levels of procalcitonin (PCT) and C-reactive protein (CRP) as indicators of the etiology and prognosis was prospectively investigated. Patients: 96 patients, 50--85 years of age, treated in the hospital for community-acquired pneumonia (CAP). Results: On admission, all patients had elevated CRP levels (&gt 10 mg/l), but only 60 patients (54%) had elevated PCT levels (&gt 0.1 ug/l). The severity of disease measured by APACHE II score was strongly associated with admission levels of PCT (p = 0.006), but not with CRP. Eight of nine patients with pneumonia caused by atypical agents had PCT levels &lt 0.5 ug/l compared with 6/27 patients with pneumonia caused by classical bacterial pathogens, mainly Streptococcus pneumoniae (p = 0.03). No such correlation between CRP levels and etiology was found. Conclusion: Our data indicate that in patients admitted to the hospital with CAP, measurement of PCT gives information about the severity of the disease, and may aid the physician to differentiate typical bacterial etiology from atypical etiology, and thereby to choose appropriate initial antibiotic treatment. Author Affiliation: (1) Div. of Infectious Diseases, Karolinska Institutet, Karolinska Hospital, S-17176 Stockholm, Sweden e-mail: jonas.hedlund@divmed.ks.se, SE (2) Div. of Clinical Chemistry, Karolinska Institutet, Karolinska Hospital, S-17176 Stockholm, Sweden e-mail: lars-olof.hansson@lab.ks.se, SE Article note: Received: June 7, 1999 * Revision accepted: January 17, 2000