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

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

Colorectal Adenomas

Carta a l'editor com a resposta al document: https://doi.org/10.1056/NEJMra1513581In his review article, Strum (March 17 issue)1 provides data on the overall prevalence of colorectal adenomas in the United States and risk factors for these lesions. It is well established that patients with Streptococcus bovis–group infective endocarditis are at high risk for colorectal cancer.2 Although a strong relationship between Enterococcus faecalis endocarditis and colorectal adenomas is suspected, robust data are lacking

What do we know about inequalities in nafld distribution and outcomes?: A scoping review

With prevalence high and rising given the close relationship with obesity and diabetes mellitus, non-alcoholic fatty liver disease (NAFLD) is progressively becoming the most common chronic liver condition worldwide. However, little is known about the health inequalities in NAFLD distribution and outcomes. This review aims to analyze health inequalities in NAFLD distribution globally and to assess the health disparities in NAFLD-related outcomes. We conducted a scoping review of global health inequalities in NAFLD distribution and outcomes according to gender/sex, ethnicity/race, and socioeconomic position from PubMed’s inception to May 2021. Ultimately, 20 articles were included in the review, most (75%) of them carried out in the United States. Males were found to have a higher NAFLD prevalence (three articles), while available evidence suggests that women have an overall higher burden of advanced liver disease and complications (four articles), whereas they are less likely to be liver-transplanted once cirrhosis develops (one article). In the US, the Hispanic population had the highest NAFLD prevalence and poorer outcomes (seven articles), whereas Whites had fewer complications than other ethnicities (two articles). Patients with low socioeconomic status had higher NAFLD prevalence (four articles) and a higher likelihood of progression and complications (five articles). In conclusion, globally there is a lack of studies analyzing NAFLD prevalence and outcomes according to various axes of inequality through joint intersectional appraisals, and most studies included in our review were based on the US population. Available evidence suggests that NAFLD distribution and outcomes show large inequalities by social group. Further research on this issue is warranted.Fil: Talens, Mar. Universitat Pompeu Fabra; EspañaFil: Tumas, Natalia. Universitat Pompeu Fabra; España. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones y Estudio sobre Cultura y Sociedad. Centro de Investigaciones de la Facultad de Psicología - Grupo Vinculado CIPSI; Argentina. University Johns Hopkins; Estados UnidosFil: Lazarus, Jeffrey V.. Universidad de Barcelona; EspañaFil: Benach, Joan. Universidad Autónoma de Madrid; España. University Johns Hopkins; Estados Unidos. Universitat Pompeu Fabra; EspañaFil: Pericàs, Juan M.. Universitat Pompeu Fabra; España. University Johns Hopkins; Estados Unidos. Vall d'Hebron Institute for Research; España. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas; Españ

Defining community-acquired pneumonia as a public health threat: arguments in favor from Spanish investigators

Despite advances in its prevention, pneumonia remains associated with high morbidity, mortality, and health costs worldwide. Studies carried out in the last decade have indicated that more patients with community-acquired pneumonia (CAP) now require hospitalization. In addition, pneumonia management poses many challenges, especially due to the increase in the number of elderly patients with multiple comorbidities, antibiotic-resistant pathogens, and the difficulty of rapid diagnosis. In this new call to action, we present a wide-ranging review of the information currently available on CAP and offer some reflections on ways to raise awareness of this disease among the general public. We discuss the burden of CAP and the importance of attaining better, faster microbiological diagnosis and initiating appropriate treatment. We also suggest that closer cooperation between health professionals and the population at large could improve the management of this largely preventable infectious disease that takes many lives each year

Non-Alcoholic Fatty Liver Disease in Patients with Polycystic Ovary Syndrome : A Systematic Review, Meta-Analysis, and Meta-Regression

Background: The metabolic effects of polycystic ovary syndrome (PCOS) may increase the risk of non-alcoholic fatty liver disease (NAFLD). However, the burden of NAFLD in PCOS has not been unequivocally defined. This systematic review (SR), meta-analysis (MA) assessed NAFLD's prevalence, and risk factors in patients with PCOS. Methods: A literature search was performed in MEDLINE, Scopus, and Scielo. First, we performed a MA of proportions to estimate the prevalence of NAFLD in PCOS. Second, we performed meta-analyses of precalculated adjusted odds ratios to examine NAFLD risk factors. Finally, we performed a meta-regression to model how the estimated prevalence changed with changes in prespecified variables. Results: We identified 817 articles from the database searches. Thirty-six were included. MA of proportions found a pooled NAFLD prevalence of 43% (95% CI, 35-52%) with high heterogeneity (I 2 = 97.2%). BMI, waist circumference, ALT values, HOMA-IR values, free androgen index levels, hyperandrogenism, and triglycerides were associated with significantly higher risk-adjusted odds of NAFLD among patients with PCOS. Meta-regression showed that rises in NAFLD prevalence were mediated through increases in metabolic syndrome prevalence and higher levels of HOMA-IR, free androgen index, and total testosterone. Conclusion: The prevalence of NAFLD (43%) among PCOS patients is high despite their average young age, with several metabolic and PCOS-specific factors influencing its occurrence. Screening programs may aid in detecting metabolic-associated fatty liver disease and prevent its consequences. Further work is required to establish the burden of liver-related outcomes once NAFLD has progressed in the PCOS population

Evaluating social and gender differences in excess weight in the Iberian Peninsula: A multilevel analysis in urban settings

Obesity is a major contributor to the burden of non-communicable diseases and related disabilities (Haththotuwa et al., 2020). Many countries have experienced alarming increases in the prevalence of excess weight in the last four decades (Hruby & Hu, 2015). Globally, obesity has almost tripled from 1975 to 2016 (Haththotuwa et al., 2020), reaching epidemic proportions (Hruby & Hu, 2015). In 2016, approximately 13% of adults (11% of men and 15% of women) were obese worldwide (WHO, 2018). Several factors (social, environmental, behavioral and biological), and levels (including individual and contextual) interact to determine the burden of overweight and obesity. Given the high velocity in the increment of excess weight, studies suggested that behavioral and environmental factors have contributed much more to the epidemic than the biological factors (Stein and Colditz, 2004; Haththotuwa et al., 2020). From a macro-level perspective, economic growth, industrialization, globalization, increases in income, rapid urbanization, and the nutritional transition are among the main drivers of the rising trends in excess weight (Hruby & Hu, 2015; Malik et al., 2013). Previous studies showed a positive association between obesity and urbanization (Mendez and Popkin, 2004; Subramanian et al., 2011), and some mechanisms were proposed to explain this association. On the one hand, living in urban settings may lead to a less energy expenditure (because of less physically demanding occupations, less opportunities to exercise, and more sedentary leisure activities). On the other hand, living in cities might lead to a faster transition to the “Western” diets high in calories, fat and sugar, and low in vegetables and fruits (Popkin et al., 2012). Several factors may underly the former, such as the increased affordability of processed and high in calories foods due to rising incomes and advances in food technologies (Goryakin & Suhrcke, 2014). The nutrition transition –i.e. the process of shifts in the diet and in the physical activity patterns that result in changes in nutritional status (Popkin., 1994)- is faster in urban settings (Hawkes et al., 2017). Urban food environments with supermarkets, high density of food stores, restaurants and street sellers, facilitate the access to unhealthy and high dense calorie diets. However, the urban environment also offers considerable opportunities to access healthy food for those who can afford it (Hawkes et al., 2017). Since healthy and low dense calorie food is often more expensive than unhealthy and high dense food, the urban poor are more likely to have access to the latter (Ruel et al., 2008; Hawkes et al., 2017). Thus, living 2 in urban areas might have different impact in overweight and obesity, depending on the social position of individuals. In Europe, 53% of adults are overweight or obese (De Schutter et al., 2020; Marques et al., 2014). In line with that, in the Iberian Peninsula (Spain and Portugal), excess weight affects more than half of the adult population (Busutil et al., 2017; Carreira et al., 2012). Janssen et al. (2020) estimated an age standardized prevalence of obesity in adult population of 22.7% in men and 24.9% in women of Portugal, and 27.5% in men and 27.2% in women of Spain in 2016. They also projected for 2060 a decrease in the obesity prevalence and in the existing gender gap in Portugal (18% and 17.7% in men and women, respectively), but an increase in the prevalence of obesity among men in Spain as well as in the gender gap (30% for men and 27% for women). Numerousstudiessuggested thatsocial position and gender are related to the excess weight in the Iberian Peninsula (Ortíz-Moncada et al., 2011; Merino Ventosa & Urbano-Garridos, 2016; Gaio et al., 2018; Hernández-Yumar et al., 2018; García-Goñi & Hernández-Quevedo, 2012; Oliveira et al., 2018; RodríguezCaro et al., 2016; Costa-Font & Gil, 2008). In Portugal, higher prevalence of overweight and obesity were found among individuals with lower educational background and women (Gaio et al., 2018; Oliveira et al., 2018). Moreover, in Spain Rodríguez-Caro et al. (2016) showed a large and rising social gradient in obesity (especially with respect to educational attainment), more noticeable among women. However, scarce evidence exists on the effect of urban social determinants beyond individual social position on excess weight, and even less about the interplay between individual- and city-level social factors in these associations in Spanish and Portuguese cities. Thus, the aims of this study are to evaluate the association between urban social indicators and excess weight by gender in cities of the Iberian Peninsula, and to analyze to what extent these associations vary by individual education.Fil: Tumas, Natalia. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad. Universidad Nacional de Córdoba. Centro de Investigaciones y Estudios sobre Cultura y Sociedad; Argentina. Universitat Pompeu Fabra; EspañaFil: Pericàs, Juan M.. Vall Dhebron University Hospital; EspañaFil: Martínez Herrera, Eliana. Universitat Pompeu Fabra; EspañaFil: Belvis Costes, Francesc. Universitat Pompeu Fabra; EspañaFil: Gutiérrez-Zamora Navarro, Mariana. Universitat Pompeu Fabra; EspañaFil: Benach, Joan. Universitat Pompeu Fabra; EspañaEuropean Population ConferenceGroningenPaíses BajosNetherlands Interdisciplinary Demographic InstituteUniversity of Groninge

Lymphopenia Is Associated With Poor Outcomes of Patients With Community-Acquired Pneumonia and Sepsis

Infecció; Limfopènia; ResultatsInfección; Linfopenia; ResultadosInfection; Lymphopenia; OutcomesBackground Lymphopenia is a marker of poor prognosis in patients with community-acquired pneumonia (CAP), yet its impact on outcomes in patients with CAP and sepsis remains unknown. We aim to investigate the impact of lymphopenia on outcomes, risk of intensive care unit (ICU) admission, and mortality in CAP patients with sepsis. Methods This was a retrospective, observational study of prospectively collected data from an 800-bed tertiary teaching hospital (2005–2019). Results Of the 2203 patients with CAP and sepsis, 1347 (61%) did not have lymphopenia, while 856 (39%) did. When compared with the nonlymphopenic group, patients with sepsis and lymphopenia more frequently required ICU admission (P = .001), had a longer hospital length of stay (P ˂ .001), and presented with a higher rate of in-hospital (P ˂ .001) and 30-day mortality (P = .001). Multivariable analysis showed that C-reactive protein ≥15 mg/dL, lymphopenia, pleural effusion, and acute respiratory distress syndrome within 24 hours of admission were risk factors for ICU admission; age ≥80 years was independently associated with decreased ICU admission. In addition, age ≥80 years, chronic renal disease, chronic neurologic disease, being a nursing home resident, lymphopenia, and pleural effusion were independently associated with increased 30-day mortality, whereas pneumococcal vaccination, diabetes mellitus, and fever were independently associated with reduced 30-day mortality. Conclusions Lymphopenia was independently associated with risk of ICU admission and higher in-hospital and 30-day mortality in patients with CAP and sepsis. Early identification of lymphopenia could help identify septic patients with CAP who require or will shortly require critical care.This study was supported by CIBER de Enfermedades Respiratorias (CIBERES CB06/06/0028) and by 2009 Support to Research Groups of Catalonia 911, IDIBAPS. Dr Cillóniz is the recipient of the SEPAR fellowship 2018 and a grant from the Fondo de Investigación Sanitaria (PI19/00207). The sponsor had no role in the design of the study, collection and analysis of the data, or preparation of the manuscript

Deaths of Despair: A Scoping Review on the Social Determinants of Drug Overdose, Alcohol-Related Liver Disease and Suicide

Death of despair; Health inequalities; Public healthMuerte de desesperación; Desigualdades en salud; Salud públicaMort de desesperació; Desigualtats en salut; Salut públicaBackground: There is a lack of consensus on the social determinants of Deaths of Despair (DoD), i.e., an increase in mortality attributed to drug overdose, alcohol-related liver disease, and suicide in the United States (USA) during recent years. The objective of this study was to review the scientific literature on DoD with the purpose of identifying relevant social determinants and inequalities related to these mortality trends. Methods: Scoping review focusing on the period 2015–2022 based on PubMed search. Articles were selected according to the following inclusion criteria: published between 1 January 2000 and 31 October 2021; including empirical data; analyzed DoD including the three causes defined by Case and Deaton; analyzed at least one social determinant; written in English; and studied DoD in the USA context only. Studies were excluded if they only analyzed adolescent populations. We synthesized our findings in a narrative report specifically addressing DoD by economic conditions, occupational hazards, educational level, geographical setting, and race/ethnicity. Results: Seventeen studies were included. Overall, findings identify a progressive increase in deaths attributable to suicide, drug overdose, and alcohol-related liver disease in the USA in the last two decades. The literature concerning DoD and social determinants is relatively scarce and some determinants have been barely studied. However different, however, large inequalities have been identified in the manner in which the causes of death embedded in the concept of DoD affect different subpopulations, particularly African American, and Hispanic populations, but blue collar-whites are also significantly impacted. Low socioeconomic position and education levels and working in jobs with high insecurity, unemployment, and living in rural areas were identified as the most relevant social determinants of DoD. Conclusions: There is a need for further research on the structural and intermediate social determinants of DoD and social mechanisms. Intersectional and systemic approaches are needed to better understand and tackle DoD and related inequalities