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Background: Stroke-associated pneumonia (SAP) has been implicated in the morbidity, mortality and increased medical cost after acute ischemic stroke. The annual cost of SAP during hospitalization in the United States approaches USD 459 million. The incidence and prognosis of SAP among intensive care unit (ICU) patients have not been thoroughly investigated. We reviewed the pathophysiology, microbiology, incidence, risk factors, outcomes and prophylaxis of SAP with special attention to ICU studies. Methods: To determine the incidence, risk factors and prognosis of acute SAP, PubMed was searched using the terms ‘pneumonia' AND ‘neurology intensive unit' and the MeSH terms ‘stroke' AND ‘pneumonia'. Non-English literature, case reports and chronic SAP studies were excluded. Studies were classified into 5 categories according to the setting they were performed in: neurological intensive care units (NICUs), medical intensive care units (MICUs), stroke units, mixed studies combining more than one setting or when the settings were not specified and rehabilitation studies. Results: The incidences of SAP in the following settings were: NICUs 4.1-56.6%, MICUs 17-50%, stroke units 3.9-44%, mixed studies 3.9-23.8% and rehabilitation 3.2-11%. The majority of NICU and MICU studies were heterogeneous including different neurovascular diseases, which partly explains the wide range of SAP incidence. The higher incidence in the majority of ICU studies compared to stroke units or acute floor studies is likely explained by the presence of mechanical ventilation, higher stroke severity causing higher rates of aspiration and stroke-induced immunodepression among ICU patients. The short-term mortality of SAP was increased among the mixed and stroke unit studies ranging between 10.1 and 37.3%. SAP was associated with worse functional outcome in the majority of stroke unit and floor studies. Mortality was less consistent among NICU and MICU studies. This difference could be due to the heterogeneity of ICU studies and the effect of small sample size or other independent risk factors for mortality such as the larger neurological deficit, mechanical ventilation, and age, which may simultaneously increase the risk of SAP and mortality confounding the outcomes of SAP itself. The pathophysiology of SAP is likely explained by aspiration combined with stroke-induced immunodepression through complex humeral and neural pathways that include the hypothalamic-pituitary-adrenal axis, parasympathetic and sympathetic systems. Conclusions: A unified definition of SAP, strict inclusion criteria, and the presence of a long-term follow-up need to be applied to the future prospective studies to better identify the incidence and prognosis of SAP, especially among ICU patients.

Background Comparison of clinical findings, chest radiographs (CXR), lung ultrasound (LUS) findings, and C‐reactive protein (CRP) concentrations at admission and serial follow‐up in dogs with aspiration pneumonia (AP) is lacking. Hypothesis Lung ultrasound lesions in dogs with AP are similar to those described in humans with community‐acquired pneumonia (comAP); the severity of CXR and LUS lesions are similar; normalization of CRP concentration precedes resolution of imaging abnormalities and more closely reflects the clinical improvement of dogs. Animals Seventeen dogs with AP. Methods Prospective observational study. Clinical examination, CXR, LUS, and CRP measurements performed at admission (n = 17), 2 weeks (n = 13), and 1 month after diagnosis (n = 6). All dogs received antimicrobial therapy. Lung ultrasound and CXR canine aspiration scoring systems used to compare abnormalities. Results B‐lines and shred signs with or without bronchograms were identified on LUS in 14 of 17 and 16 of 17, at admission. Chest radiographs and LUS scores differed significantly using both canine AP scoring systems at each time point (18 regions per dog, P < .001). Clinical and CRP normalization occurred in all dogs during follow up. Shred signs disappeared on LUS in all but 1 of 6 dogs at 1 month follow‐up, while B‐lines and CXR abnormalities persisted in 4 of 6 and all dogs, respectively. Conclusion and Clinical Importance Lung ultrasound findings resemble those of humans with comAP and differ from CXR findings. Shred signs and high CRP concentrations better reflect clinical findings during serial evaluation of dogs.

To identify markers associated with in-hospital death in patients with coronavirus disease 2019 (COVID-19)–associated pneumonia. A retrospective cohort study was conducted of 140 patients with moderate to critical COVID-19–associated pneumonia requiring oxygen supplementation admitted to the hospital from January 28, 2020, through February 28, 2020, and followed up through March 13, 2020, in Union Hospital, Wuhan, China. Oxygen saturation (SpO2) and other measures were tested as predictors of in-hospital mortality in survival analysis. Of 140 patients with COVID-19–associated pneumonia, 72 (51.4%) were men, with a median age of 60 years. Patients with SpO2 values of 90% or less were older and were more likely to be men, to have hypertension, and to present with dyspnea than those with SpO2 values greater than 90%. Overall, 36 patients (25.7%) died during hospitalization after median 14-day follow-up. Higher SpO2 levels after oxygen supplementation were associated with reduced mortality independently of age and sex (hazard ratio per 1-U SpO2, 0.93; 95% CI, 0.91 to 0.95; P<.001). The SpO2 cutoff value of 90.5% yielded 84.6% sensitivity and 97.2% specificity for prediction of survival. Dyspnea was also independently associated with death in multivariable analysis (hazard ratio, 2.60; 95% CI, 1.24 to 5.43; P=.01). In this cohort of patients with COVID-19, hypoxemia was independently associated with in-hospital mortality. These results may help guide the clinical management of patients with severe COVID-19, particularly in settings requiring strategic allocation of limited critical care resources. Chictr.org.cn Identifier: ChiCTR2000030852

Introduction and ObjectivesUp to 5% of patients with COVID 19 become seriously unwell due to respiratory failure of which a proportion require referral to the Intensive Care Unit (ICU). We designed a protocol to use CPAP early on the respiratory ward in confirmed Covid patients to reduce the need for ICU. Clinical trials are ongoing examining the effectiveness of CPAP versus other forms of oxygen delivery in reducing mortality.1 MethodsCovid patients in respiratory failure for escalation to ICU were considered for a trial of CPAP when their oxygen requirements exceeded 4L/minute. CPAP was started at a positive end expiratory pressure (PEEP) of 5 cm H2O and up titrated to maintain oxygen saturations greater than 94%. Demographic information, PEEP pressures, duration on CPAP, time to intubation if CPAP failed, ICU admission, hospital discharge and 60 day mortality was collected on CPAP responders and CPAP non responders over a six-week period.Results43/353 patients (12%) admitted with Covid pneumonia to our hospital in respiratory failure were deemed suitable for a CPAP trial and were for escalation to ICU if CPAP failed. (Table 1). 23/43 (54%) responded favourably to CPAP and avoided ICU. Males were more likely to fail CPAP (48% vs 75%, p=0.07) within the first day (5 vs 1 day, p≤0.001). Hospital length of stay in CPAP responders was considerably shorter than CPAP non responders.Abstract P57 Table 1Differences between CPAP responders and CPAP non responders in Covid Pneumonia patients Variable CPAP responder (n= 23) CPAP non responder (n =20 ) p value Mean Age (years)52.9 (±12.8) 52.7 (±9.1)p=0.95Gender (%)42% male70% female57% male30% femalep=0.07Comorbidites-HypertensionIschaemic heart diseaseDiabetesCOPD5/23 (22%)0/233/23 (13%)2/23 (9%)7/20 (35%)0/205/20 (25%)0/20p=0.5p=1p=0.43p=0.4Body mass index (BMI)29.5 (28–37)31.5 (29–39)p=0.4FiO2 pre CPAP0.32 (0.32–0.6)0.4 (0.32–0.5)P=0.6Median Initial PEEP (cmH2O)Median Maximum PEEP (cmH2O)5 (5–10)10 (8–10)5 (5–10)10 (10–10)p=0.9p=0.7Median days on CPAP5 (3–7)1 (0–2)p≤0.001*Hospital length of stay (days)10 (8–11)18 (14–39)p≤0.0001*Hospital discharge100%100%60-day survival100%100%ConclusionsOver half of patients trialled on CPAP tolerated it well and avoided ICU admission with a shorter hospital stay. These were younger patients with relatively few comorbidities. Those who failed CPAP were mostly male and did so within the first 24 hours. The non-responders to CPAP all survived to hospital discharge. Early CPAP use in this group has had no adverse outcomes to date. More work is needed to look at the use of early CPAP in older patients with more medical co-morbidities in respiratory failure due to Covid pneumonia.ReferenceRECOVERY-RS Respiratory support : respiratory strategies in COVID-19; CPAP, High-flow, and standard care. Available: http://www.isrctn.com/ISRCTN16912075

Summary About 200 million cases of viral community-acquired pneumonia occur every year—100 million in children and 100 million in adults. Molecular diagnostic tests have greatly increased our understanding of the role of viruses in pneumonia, and findings indicate that the incidence of viral pneumonia has been underestimated. In children, respiratory syncytial virus, rhinovirus, human metapneumovirus, human bocavirus, and parainfluenza viruses are the agents identified most frequently in both developed and developing countries. Dual viral infections are common, and a third of children have evidence of viral-bacterial co-infection. In adults, viruses are the putative causative agents in a third of cases of community-acquired pneumonia, in particular influenza viruses, rhinoviruses, and coronaviruses. Bacteria continue to have a predominant role in adults with pneumonia. Presence of viral epidemics in the community, patient's age, speed of onset of illness, symptoms, biomarkers, radiographic changes, and response to treatment can help differentiate viral from bacterial pneumonia. However, no clinical algorithm exists that will distinguish clearly the cause of pneumonia. No clear consensus has been reached about whether patients with obvious viral community-acquired pneumonia need to be treated with antibiotics. Apart from neuraminidase inhibitors for pneumonia caused by influenza viruses, there is no clear role for use of specific antivirals to treat viral community-acquired pneumonia. Influenza vaccines are the only available specific preventive measures. Further studies are needed to better understand the cause and pathogenesis of community-acquired pneumonia. Furthermore, regional differences in cause of pneumonia should be investigated, in particular to obtain more data from developing countries.

Pneumonia kills more children each year worldwide than any other disease. Nonetheless, accurately determining the causes of childhood pneumonia has remained elusive. Over the past century, the focus of pneumonia etiology research has shifted from studies of lung aspirates and postmortem specimens intent on identifying pneumococcal disease to studies of multiple specimen types distant from the lung that are tested for multiple pathogens. Some major challenges facing modern pneumonia etiology studies include the use of nonspecific and variable case definitions, poor access to pathologic lung tissue and to specimens from fatal cases, poor diagnostic accuracy of assays (especially when testing nonpulmonary specimens), and the interpretation of results when multiple pathogens are detected in a given individual. The future of childhood pneumonia etiology research will likely require integrating data from complementary approaches, including applications of advanced molecular diagnostics and vaccine probe studies, as well as a renewed emphasis on lung aspirates from radiologically confirmed pneumonia and postmortem examinations.

In 2002 the American Thoracic Society/European Respiratory Society (ATS/ERS) classification of idiopathic interstitial pneumonias (IIPs) defined seven specific entities, and provided standardized terminology and diagnostic criteria. In addition, the historical \"gold standard\" of histologic diagnosis was replaced by a multidisciplinary approach. Since 2002 many publications have provided new information about IIPs. The objective of this statement is to update the 2002 ATS/ERS classification of IIPs. An international multidisciplinary panel was formed and developed key questions that were addressed through a review of the literature published between 2000 and 2011. Substantial progress has been made in IIPs since the previous classification. Nonspecific interstitial pneumonia is now better defined. Respiratory bronchiolitis-interstitial lung disease is now commonly diagnosed without surgical biopsy. The clinical course of idiopathic pulmonary fibrosis and nonspecific interstitial pneumonia is recognized to be heterogeneous. Acute exacerbation of IIPs is now well defined. A substantial percentage of patients with IIP are difficult to classify, often due to mixed patterns of lung injury. A classification based on observed disease behavior is proposed for patients who are difficult to classify or for entities with heterogeneity in clinical course. A group of rare entities, including pleuroparenchymal fibroelastosis and rare histologic patterns, is introduced. The rapidly evolving field of molecular markers is reviewed with the intent of promoting additional investigations that may help in determining diagnosis, and potentially prognosis and treatment. This update is a supplement to the previous 2002 IIP classification document. It outlines advances in the past decade and potential areas for future investigation.

The coronavirus disease 2019 (COVID-19) pandemic emerged in Wuhan, China, in late 2109, and has rapidly spread around the world. Until May 25, 2020, there were 133,521 confirmed COVID-19 cases and 7359 deaths in Iran. The role of opportunistic fungal infections in the morbidity and mortality of COVID-19 patients remains less defined. Based on our multicenter experiences, we categorized the risks of opportunistic fungal infections in COVID-19 patients in Iran. The COVID-19 patients at high risk included those with acute respiratory distress syndrome, in intensive care units, receiving broad-spectrum antibiotics, immunosuppressants or corticosteroid, and supported by invasive or noninvasive ventilation. The patients were most likely to develop pulmonary aspergillosis, oral candidiasis, or pneumocystis pneumonia. Most diagnoses were probable as the accurate diagnosis of opportunistic fungal infections remains challenging in resource-poor settings. We summarize the clinical signs and laboratory tests needed to confirm candidiasis, aspergillosis, or pneumocystosis in our COVID-19 patients.

Necrotizing pneumonia induced by Panton-Valentine leukocidin-secreting Staphylococcus aureus is a rare but life-threatening infection that has been described in patients after they had influenza. We report a fatal case of this superinfection in a young adult who had coronavirus disease.

BackgroundUnplanned admissions of neuromuscular patients adversely affect patients and NHS. Muscular dystrophy UK designed an audit of unplanned admissions of neuromuscular patients in 2012 and 2017.AimWe aimed to compare unplanned admissions amongst myasthenia gravis (MG) patients, in two different hospitals in Wessex, Southampton general hospital (SGH) and Queen Alexandra service (QAH).MethodsData was collected from patients attending neurology clinics in conjunction with hospital database.Results240 adult patients were included in the audit. 60 unplanned hospital admissions were identified, but only 22 (37%) were judged to be potentially avoidable. 8 admissions were due to myasthenia relapse, 8 occurred in patients with severe myasthenia on dual immunosuppression. 9 admissions were due to pneumonia in elderly patients with multiple comorbidities but well controlled myasthenia. 2 admissions were anxiety related and 3 were due to falls and fracture despite appropriate bone protection.ConclusionOur preventable admission rate for MG patients is less compared to MDUK data (37% vs 68.7% and 59.4% in 2012 and 2017). Pneumonia is common in elderly myasthenic patients who have other comorbidities. Fragility fractures can occur despite bone protection and falls advice is necessary during consultation.