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Background: Although electronic cigarettes (e-cigarettes) may help some smokers quit, some young adult never-smokers are now using e-cigarettes recreationally, potentially increasing their risk for initiation of smoking. We aimed to determine the association between baseline e-cigarette use and subsequent initiation of cigarette smoking among initially never-smoking young adults., Methods: We conducted a prospective cohort study with assessments at baseline (March 2013) and follow-up (October 2014). We used sampling frames representing 97% of the US population to recruit a nationally representative sample of never-smoking young adults aged 18 to 30 years. The independent variable was baseline ever use of e-cigarettes. The main outcome measure was initiation of traditional cigarette smoking between baseline and 18-month follow-up., Results: Baseline surveys were completed by 1506 never-smoking young adults, of whom 915 (60.8%) completed follow-up. There were no demographic differences between responders and nonresponders. After applying survey weights-which accounted for both nonresponse and overcoverage or undercoverage-2.5% of the represented population of never-smokers (801,010 of 32,040,393) used e-cigarettes at baseline. Cigarette smoking was initiated by 47.7% of e-cigarette users and 10.2% of nonusers (P = .001). In fully adjusted multivariable models, e-cigarette use at baseline was independently associated with initiation of smoking at 18 months (adjusted odds ratio, 6.8; 95% confidence interval, 1.7-28.3). Results remained similar in magnitude and statistically significant in all sensitivity analyses., Conclusions: Baseline e-cigarette use was independently associated with initiation of traditional cigarette smoking at 18 months. This finding supports policy and educational interventions designed to decrease use of e-cigarettes among nonsmokers., (Copyright © 2018. Published by Elsevier Inc.)

Background: Although processes of care are common proxies for health care quality, their associations with medical outcomes remain uncertain., Methods: For 2076 patients hospitalized with pneumonia from 32 emergency departments, we used multilevel logistic regression modeling to assess independent associations between patient outcomes and the performance of 4 individual processes of care (assessment of oxygenation, blood cultures, and rapid initiation [<4 hours] and appropriate selection of antibiotic therapy) and the cumulative number of processes of care performed., Results: Overall, 141 patients (6.8%) died. Mortality was 0.3% to 1.7% lower for patients who had each of the individual processes of care performed (P≥.13 for each comparison); mortality was 7.5% for patients who had 0 to 2 processes of care, 7.2% for those with 3 processes of care, and 5.8% for those with all 4 processes of care performed (P=.39). Mortality was not significantly associated with either individual or cumulative process measures in multivariable models., Conclusion: Neither the individual processes of care nor the cumulative number performed is associated with short-term mortality for pneumonia., (Published by Elsevier Inc.)

Background: Many physicians recommend that patients receive follow-up chest imaging after the diagnosis of pneumonia to ensure that a pulmonary malignancy is not missed. However, there is little research evidence to support this practice. Our aims were to assess the frequency of the diagnosis of pulmonary malignancy, and to identify risk factors for pulmonary malignancy following hospitalization for pneumonia., Methods: By excluding patients with a prior diagnosis of pulmonary malignancy, we examined the incidence of a new pulmonary malignancy diagnosis in inpatients aged >/=65 years with a discharge diagnosis of pneumonia in fiscal years 2002-2007, and at least 1 year of Department of Veterans Affairs outpatient care before the index admission., Results: Of 40,744 patients hospitalized with pneumonia, 3760 (9.2%) patients were diagnosed with pulmonary malignancy after their index pneumonia admission. Median time to diagnosis was 297 days, with only 27% diagnosed within 90 days of admission. Factors significantly associated with a new diagnosis of pulmonary malignancy included history of chronic pulmonary disease, any prior malignancy, white race, being married, and tobacco use. Increasing age, Hispanic ethnicity, need for intensive care unit admission, and a history of congestive heart failure, stroke, dementia, or diabetes with complications were associated with a lower incidence of pulmonary malignancy., Conclusion: A small, but clinically important, proportion of patients are diagnosed with pulmonary malignancy posthospitalization for pneumonia. Additional research is needed to examine whether previously undiagnosed pulmonary malignancies might be detected at admission, or soon after, for those hospitalized with pneumonia., (Published by Elsevier Inc.)

Background: Studies that have assessed antibiotic appropriateness in acute respiratory tract infections (RTIs) with a likely bacterial etiology have focused only on antibiotic choice and ignored other important aspects of prescribing, such as dosing, drug-drug interactions, and duration of treatment., Objective: The aim of this study was to determine the prevalence and predictors of inappropriate antibiotic prescribing practices in outpatients with acute bacterial RTIs (community-acquired pneumonia [CAP], sinusitis, or acute exacerbations of chronic bronchitis [AECB])., Methods: This retrospective, cross-sectional study enrolled outpatients with CAP, sinusitis, or AECB who were evaluated in a Veterans Affairs emergency department over a 1-year period. Using electronic medical records, trained research assistants completed data-collection forms that included patient characteristics (eg, marital status, history of alcohol abuse), diagnosis, comorbidities, concurrent medications, and antibiotics prescribed. To assess antimicrobial appropriateness, a trained clinical pharmacist reviewed the data-collection forms and applied a Medication Appropriateness Index (MAI), which rated the appropriateness of a medication using 10 criteria: indication, effectiveness, dosage, directions, practicality (defined as capability of being used or being put into practice), drug-drug interactions, drug-disease interactions, unnecessary duplication, duration, and expensiveness (defined as the cost of the drug compared with other agents of similar efficacy and tolerability). Previous studies have found good inter- and intrarater reliabilities between a clinical pharmacist's and an internal medicine physician's MAI ratings (kappa=0.83 and 0.92, respectively)., Results: One hundred fifty-three patients were included (mean age, 58 years; 92% male; and 65% white). Overall, 99 of 153 patients (65%) had inappropriate antibiotic prescribing as assessed using the MAI. Expensiveness (60 patients [39%]), impracticality (32 [21%]), and incorrect dosage (15 [10%]) were the most frequently rated problem. Penicillins, quinolones, and macrolides were the most common antibiotic classes prescribed inappropriately. A history of alcohol abuse was associated with a lower likelihood of inappropriate prescribing compared with no history of alcohol abuse (adjusted odds ratio [AOR], 0.32; 95% CI, 0.10-0.98), while patients who were married were more likely to receive inappropriately prescribed antibiotics than those who were not married (AOR, 2.64; 95% CI, 1.25-5.59)., Conclusions: Inappropriate antibiotic prescribing based on the MAI criteria was common (65%) in this selected patient population with acute bacterial RTIs, and often involved problems with expensiveness (39%), impracticality (21%), and incorrect dosage (10%). Future interventions to improve antibiotic prescribing should consider aspects beyond choice of agent.

We found a high white blood cell count (>11,000/mul) to be of additive prognostic value to high troponin-I levels in predicting risk of recurrent nonfatal myocardial infarctions and all-cause mortality in patients who present with acute coronary syndromes and non-ST-elevation myocardial infarctions. A high troponin-I level or white blood cell count increased the odds ratio of an event to 2.2 (95% confidence interval 1.0 to 4.73, p = 0.05), but high values for the 2 markers increased the odds ratio to 4.5 (95% confidence interval 1.42 to 14.21, p = 0.01).

Purpose: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores., Subjects and Methods: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios., Results: The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score <1 (51% [1635/3181]) or a CURB-65 score <2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P <0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score., Conclusions: The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.

Purpose: Patients with pneumonia often remain hospitalized after they are stable clinically, and the duration of intravenous antibiotic therapy is a rate-limiting step for discharge. The purpose of this study was to determine whether implementation of an evidence-based guideline would reduce the duration of intravenous antibiotic therapy and length of stay for patients hospitalized with pneumonia., Methods: In a seven-site, cluster randomized clinical trial, we enrolled 325 control and 283 intervention patients who were admitted by one of 116 physician groups. Within site, physician groups were assigned randomly to receive a practice guideline alone (control arm) or a practice guideline that was implemented using a multifaceted strategy (intervention arm). The effectiveness of guideline implementation was measured by the duration of intravenous antibiotic therapy and length of stay; differences in the rates of discontinuation and hospital discharge were assessed with proportional hazards models. Medical outcomes were assessed at 30 days., Results: Intravenous antibiotic therapy was discontinued somewhat more quickly in the intervention group (hazard ratio [HR] =1.23; 95% confidence interval [CI]: 1.00 to 1.52; P = 0.06) than in the control group. Intervention patients were discharged more quickly, but the difference was not statistically significant (HR = 1.16; 95% CI: 0.97 to 1.38; P = 0.11). Fewer intervention (55% [157/283]) than control (63% [206/325]) patients had medical complications during the index hospitalization (P = 0.04), with no differences in other medical outcomes, including mortality, rehospitalization, and return to usual activities, between treatment arms., Conclusions: The multifaceted guideline implementation strategy resulted in a slight reduction in the duration of intravenous antibiotic therapy and a nonsignificant reduction in length of stay, without affecting patient outcomes.

Background: Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients., Methods: A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age > or =66 years and an office visit after September 30, 1998., Results: Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P <0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P <0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P <0.001)., Conclusion: Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions.

Purpose: Patients with pneumonia often remain hospitalized after becoming clinically stable, without demonstrated benefits on outcome. The purposes of this study were to assess the relation between length of hospital stay and daily medical care costs and to estimate the potential cost savings associated with a reduced length of stay for patients with pneumonia., Subjects and Methods: As part of a prospective study of adults hospitalized with community-acquired pneumonia at a community hospital and two university teaching hospitals, daily medical care costs were estimated by multiplying individual charges by department-specific cost-to-charge ratios obtained from each hospital's Medicare cost reports., Results: The median total cost of hospitalization for all 982 inpatients was $5, 942, with a median daily cost of $836, including $491 (59%) for room and $345 (41%) for non-room costs. Average daily non-room costs were 282% greater on the first hospital day, 59% greater on the second day, and 19% greater on the third day than the average daily cost throughout the hospitalization (all P <0.05), and were 14% to 72% lower on the last 3 days of hospitalization. Average daily room costs remained relatively constant throughout the hospital stay, with the exception of the day of discharge. A projected mean savings of $680 was associated with a 1-day reduction in length of stay., Conclusions: Despite institutional differences in total costs, patterns of daily resource use throughout hospitalization were similar at all institutions. A 1-day reduction in length of stay might yield substantial cost-savings.

Purpose: To assess the variation in length of stay for patients hospitalized with community-acquired pneumonia and to determine whether patients who are treated in hospitals with shorter mean stays have worse medical outcomes., Subjects and Methods: We prospectively studied a cohort of 1,188 adult patients with community-acquired pneumonia who had been admitted to one community and three university teaching hospitals. We compared patients' mean length of stay, mortality, hospital readmission, return to usual activities, return to work, and pneumonia-related symptoms among the four study hospitals. All outcomes were adjusted for baseline differences in severity of illness and comorbidity., Results: Adjusted interhospital differences in mean length of stay ranged from 0.9 to 2.3 days (P <0.001). When the risk of each medical outcome was compared between patients admitted to the hospital with the shortest length of stay and those admitted to longer stay hospitals, there were no differences in mortality [relative risk (RR) = 0.7; 95% CI, 0.3 to 1.7], hospital readmission (RR = 0.8; 95% CI, 0.5 to 1.2), return to usual activities (RR = 1.1; 95% CI, 0.9 to 1.3), or return to work (RR = 1.2; 95% CI, 0.8 to 2.0) during the first 14 days after discharge, or in the mean number of pneumonia-related symptoms 30 days after admission (P = 0.54)., Conclusions: We observed substantial interhospital variation in the lengths of stay for patients hospitalized with community-acquired pneumonia. The finding that medical outcomes were similar in patients admitted to the hospital with the shortest length of stay and those admitted to hospitals with longer mean lengths of stay suggests that hospitals with longer stays may be able to reduce the mean duration of hospitalization for this disease without adversely affecting patient outcomes.

Purpose: To assess the patterns of antimicrobial use, costs of antimicrobial therapy, and medical outcomes by institution in patients with community-acquired pneumonia., Patients and Methods: The route, dose, and frequency of administration of all antimicrobial agents prescribed within 30 days of presentation were recorded for 927 outpatients and 1328 inpatients enrolled in the Pneumonia Patient Outcomes Research Team (PORT) multicenter, prospective cohort study. Total antimicrobial costs were estimated by summing drug costs, using average wholesale price for oral agents and institutional acquisition prices for parenteral agents, plus the costs associated with preparation and administration of parenteral therapy. Thirty-day outcome measures were mortality, subsequent hospitalization for outpatients, and hospital readmission for inpatients., Results: Significant variation (P <0.05) in prescribing practices occurred for 17 of the 23 antimicrobial agents used in outpatients across 5 treatment sites, and for 18 of the 20 parenteral agents used in inpatients across 4 treatment sites. The median duration of antimicrobial therapy for treatment site ranged from 11 to 13 days for outpatients (P=0.01), and from 13 to 15 days for inpatients (P=0.49). The overall median cost of antimicrobial therapy was $12.90 for outpatients, and ranged from $10.80 to $58.90 among treatment sites (P <0.0001). The overall median cost of antimicrobial therapy was $228.70 for inpatients, and ranged from $183.70 to $315.60 among sites (P <0.0001). Mortality and hospital readmission for inpatients were not significantly different across sites after adjusting for baseline differences in patient demographic characteristics, comorbidity, and illness severity. Although subsequent hospitalization for outpatients differed by site, the rate was lowest for the site with the lowest antimicrobial costs., Conclusion: Variations in antimicrobial prescribing practices by treatment site exist for outpatients and inpatients with community-acquired pneumonia. Although variation in antimicrobial prescribing practices across institutions results in significant differences in antimicrobial costs, patients treated at institutions with the lowest antimicrobial costs do not demonstrate worse medical outcomes.

Objectives: To determine the etiology of community-acquired pneumonia in patients treated in an ambulatory setting, using serological methods, and to compare presenting symptoms, radiographic manifestations, and clinical outcomes of patients with pneumonia of "atypical" and undetermined etiology., Patients and Methods: This prospective cohort study was conducted in emergency room and outpatient facilities of Victoria General Hospital, Halifax, Nova Scotia, and in offices of participating family doctors based in Halifax. One hundred forty-nine adults with acute onset of one or more symptoms or signs suggestive of pneumonia and radiographic evidence of pneumonia who provided informed consent were enrolled. Patients known to be HIV positive or who had been discharged from a hospital within the previous 10 days were ineligible for enrollment. Demographic features and clinical data were collected by direct patient interview and chart review by trained research nurses. Outcome measures included quantitative evaluation of pneumonia-specific symptoms, and responses to the Short Form 36 Health Survey at presentation and at 30 days after presentation. Information was also collected on each patient's health prior to pneumonia, as well as the time until each patient's self-reported return to work and to usual activities. The etiology of pneumonia was determined by testing acute and convalescent serum samples for antibodies to Legionella pneumophila serogroup 1, Mycoplasma pneumoniae, Chlamydia pneumoniae, Chlamydia psittaci, Coxiella burnetii, adenovirus, respiratory syncytia virus, influenza viruses A and B, and parainfluenza viruses 1, 2, 3., Results: The study population consisted of 149 patients, 54 (36%) of whom were men, with a mean age (+/- SD) of 41 +/- 15 years. An etiological diagnosis was made in 74 (49.7%) patients using serological methods. Etiological agents included M pneumoniae 34 (22.8%); C pneumoniae 16 (10.7%); M pneumoniae and C pneumoniae 5 (3.4%); C burnetii 4 (2.7%); influenza A virus 4 (2.7%); and other agents 6% (7.4%). Three patients (2%) had a conventional bacterial etiology, and 72 patients (48.3%) had pneumonia of undetermined etiology. Patients with pneumonia of known (atypical) and undetermined etiology were similar in terms of age, gender, race, education, employment, and comorbidity. Despite a higher proportion of patients with pneumonia of known etiology reporting sweats, chills, and headache at presentation, the two groups were similar for symptom severity and bother. The patients with pneumonia of undetermined etiology were more likely to have multilobar pneumonia (P < 0.02). Both patients with atypical pneumonia and those with pneumonia of undetermined etiology suffered severe deterioration of physical functioning with a marked but incomplete recovery at 30 days. Those with atypical pneumonia had higher physical functioning and general mental health scores at 30 days., Conclusions: Nearly half the cases of ambulatory community-acquired pneumonia are due to "atypical" agents. It is not possible to reliably distinguish patients with atypical pneumonia from those with pneumonia of undetermined etiology by clinical features at baseline. The outcomes in terms of resolution of symptoms, functional status, return to work, and return to usual activities are essentially similar in the two groups.

Objectives: To identify the etiologies and risk factors associated with fever of nosocomial origin and compare the outcomes of patients with and without nosocomial fever., Design: A prospective study with a case-control component., Setting: The three medical services of a university hospital., Patients and Methods: We evaluated 100 patients with fever of nosocomial origin. Etiologies were assigned by the consensus of three independent reviewers using Centers for Disease Control guidelines. Predictors of bacterial etiology were identified using logistic regression methods. Controls matched for age (+/- 5 years), sex, and comorbidity were identified for 65 of the nosocomial fever cases. Cases and controls were compared with conditional logistic regression to identify risk factors for fever of nosocomial origin. Cases and controls were followed at 1 month to compare length of stay, mortality, and hospital readmission rates., Measurements and Main Results: An etiology was assigned in 81 cases: 51 had bacterial infection, 5 had nonbacterial infection, and 25 had a noninfectious etiology. Multivariate predictors of bacterial infection were the presence of diabetes mellitus (odds ratio [OR] = 5.74; 95% confidence interval of the odds ratio [CI] = 1.61 to 20.40), length of stay to fever onset after admission greater than 10 days (OR = 3.98, CI = 1.04 to 15.22), maximum temperature greater than 38.7 degrees C (OR = 3.37, CI = 1.28 to 8.88), and white blood cell count greater than 10 x 10(9)/L (OR = 4.64, CI = 1.68 to 12.77). Comparison of cases and controls indicated that patients with nosocomial fever had more invasive procedures in the 72 hours preceding enrollment in the study than controls (OR = 1.46, CI = 1.03 to 2.08). Although cases were hospitalized almost twice as long as controls (21.5 versus 12.5 days; p < 0.0001), neither 30-day mortality nor hospital readmission rates differed between cases and controls., Conclusion: Nosocomial fever often does not represent nosocomial infection and may constitute a wide variety of other conditions. Since bacterial etiology of fever is a major concern, clinical and laboratory findings can be used to predict patients at high risk for an infectious process. A reduction in the number of invasive procedures may decrease the incidence of nosocomial fever. New-onset nosocomial fever leads to an increase in length of hospital stay but is not a significant predictor of mortality.

Purpose: Our purpose was to validate a previously developed pneumonia-specific prognostic index in a large, multicenter population., Patients and Methods: We developed a pneumonia-specific prognostic index in a prospective, multicenter study of 346 patients with clinical and radiographic evidence of pneumonia admitted to 3 Pittsburgh hospitals (the derivation cohort), and validated the index in 14,199 patients with a principal ICD-9-CM diagnosis of pneumonia admitted to 78 hospitals in the 1989 MedisGroups Comparative Hospital Database (the validation cohort). The prognostic index classified patients into five ordered risk classes based on six predictors of mortality: age greater than 65 years, pleuritic chest pain, a vital sign abnormality, altered mental status, neoplastic disease, and high-risk pneumonia etiology. Each patient in the validation cohort was assigned to a risk class by obtaining values for the index's six predictors in the MedisGroups population. The performance of the prognostic index in the derivation and validation cohorts was assessed by comparing hospital mortality rates within each of the index's five prognostic risk classes., Results: The hospital mortality rate was 13.0% in the derivation cohort, and 11.1% in the validation cohort (p = 0.26). The agreement in the risk class-specific mortality rates was striking with the exception of class V: in class I, mortality was 0% in the derivation cohort versus 1% in the validation cohort; in class II, 0% versus 1.1%; class III, 10.9% versus 8.6%; class IV, 21.8% versus 26.2%; and class V, 73.7% versus 37.7%. There were no statistically significant differences in mortality rates within the first four risk classes, which represented the vast majority of patients in the derivation (94%) as well as the validation (98%) cohorts., Conclusions: These data support the generalizability of a pneumonia-specific prognostic index. This index, which performs exceptionally well in classifying low-risk patients, may help physicians identify patients with community-acquired pneumonia who could safely be managed in the ambulatory setting, or if hospitalized, the patients that could be treated with abbreviated inpatient care.

Background and Methods: The incidence and risk factors for erythromycin-induced ototoxicity are unknown. We conducted a prospective, nested case-control study of assessment of auditory function in patients receiving erythromycin versus other antibiotics (control group) for community-acquired pneumonia. Sequential audiograms were performed during antibiotic therapy for both cases and controls by an audiologist unaware of the identity of the therapy administered. Erythromycin serum concentrations were obtained for all patients receiving erythromycin., Results: Symptomatic ototoxicity (tinnitus or hearing loss) confirmed by audiograms was documented in five of 30 patients receiving erythromycin and none of 15 receiving other antibiotics. Ototoxicity was significantly related to high peak concentration and high AUC 0-infinity as a function of decreased total systemic clearance. Ototoxicity occurred only in those patients who received 4 g/day versus 2 g/day or no erythromycin (p = 0.05). Ototoxicity resolved in all patients within 6 to 14 days after discontinuation of therapy., Conclusions: Erythromycin ototoxicity is dose- and serum concentration-dependent. Patients receiving erythromycin, especially at a total daily dose of 4 g, should be monitored regularly for subjective evidence of sensorineural hearing dysfunction. Ototoxicity is reversible if the diagnosis is made early in the course.

Purpose: We evaluated management decisions of house staff in a university hospital emergency department (ED) to determine the impact of baseline electrocardiogram (ECG) results on the care of elderly patients., Subjects and Methods: The study employed a prospective before-after research design. The subjects included internal medicine house staff assigned to the ED and the 47 elderly patients treated by them during 58 ED visits. The measures of impact on patient care included how often and in what ways comparison of baseline and ED ECG results changed the house staff's diagnostic impressions and treatment plans. To determine changes, we asked house staff to indicate their impressions and management plans before and after comparing baseline and ED ECG results. In addition, a panel of faculty members used a modification of the nominal group process to determine treatment changes and to estimate benefit to patients from the changes., Results: House staff indicated that baseline ECG results led them to change diagnostic impressions during 13 (22%) and treatment plans during eight (14%) of the 58 visits. Six of the patients benefited from the treatment changes. The faculty judges indicated that baseline ECG findings would have altered their diagnostic impressions in eight (14%) and treatment decisions in three (5%) of the 58 cases, one of which would have benefited from the change. All patients for whom there were changes of impression or plan had prior histories of cardiovascular disease., Conclusion: We conclude that baseline ECGs provide ED house staff with diagnostic information that often leads to changes in management of elderly patients with prior histories of cardiovascular disease. Future studies should evaluate the efficacy of baseline ECGs in patients without such histories.

Purpose: To identify a low-risk subset of patients with community-acquired pneumonia that could safely be treated in the ambulatory setting; and to assess how clinicians make the hospitalization decision., Patients and Methods: We performed a prospective, observational study of 280 ambulatory and hospitalized adults with clinical and radiographic evidence of pneumonia. Patients were followed to assess all potential morbid complications and 6-week mortality. Physicians responsible for managing these patients were surveyed to assess the reasons for treating in a hospital or ambulatory setting and the therapies that dictate hospitalization., Results: Sixty-one percent (170 of 280) of patients did not have an indication for admission at presentation using modified Appropriateness Evaluation Protocol criteria (a severe vital sign abnormality, alteration in mental status, suppurative complication, arterial hypoxemia, severe laboratory abnormality, or an acute coexistent medical problem requiring admission independent of the pneumonia). Among these 170 patients, 38% had a complicated course defined as death within 6 weeks, development of a new suppurative or medical complication due to pneumonia, intensive care unit admission, persistent fever or use of intravenous fluids or oxygen beyond 3 days, hospitalization lasting more than 3 days, or subsequent hospitalization in patients initially treated in the ambulatory setting. Five predisposing factors for a complicated course were identified in logistic regression models. The odds ratio for age more than 65 years was 2.7; for comorbid illness, 3.2; for temperature more than 38.3 degrees C (101 degrees F), 4.1; for immunosuppression, 12.0; and for a high-risk etiology, 23.3. The risk of a complicated course increased linearly with the number of risk factors, from 12% with none to 100% with four or more factors (p less than 0.001). Physicians most often relied on the general clinical appearance of the patient when making the triage decision, and most commonly cited intravenous antibiotics and chest physical therapy as treatments requiring hospitalization., Conclusions: If validated, our findings could improve physicians' assessment of prognosis, and may identify a low-risk subset of patients with community-acquired pneumonia who could safely be managed in the ambulatory setting.

Purpose: Our purpose was to determine which clinical features predict short-term mortality in patients with community-acquired pneumonia., Patients and Methods: We conducted a prospective multicenter study of 347 patients hospitalized in Pittsburgh (the derivation cohort) and 253 hospitalized and ambulatory patients in Boston (the validation cohort) with clinical and radiographic evidence of pneumonia. Patients in the derivation cohort underwent an extensive microbiologic evaluation including bacteriologic sputum culture, blood cultures, direct fluorescent antibody testing for Legionella species, and serologic testing for Mycoplasma pneumoniae, Legionella species, and Chlamydia TWAR., Results: The overall mortality was 18% in the derivation cohort and 13.2% in the validation cohort. We identified five independent predictors of mortality in the derivation cohort: pleuritic chest pain (risk ratio, 0.4; 95% confidence interval [CI], 0.17 to 0.99), mental status changes (risk ratio, 2.6; 95% CI, 1.4 to 4.6), a severe vital sign abnormality (risk ratio, 2.1; 95% CI 1.2 to 3.6), neoplastic disease (risk ratio, 5.0; 95% CI, 2.7 to 9.1), and "high-risk" pneumonia etiology (risk ratio, 2.8; 95% CI, 1.6 to 5.0). A mortality index based on these factors accurately classified patients into five risk classes of increasing mortality. In the derivation cohort, the 6-week mortality rates were 0% in class I, 2.9% in class II, 13.1% in class III, 32.7% in class IV, and 89.5% in class V. There was little deterioration in the predictive accuracy of the model when tested in the validation cohort: mortality was 2.2% in class I, 0% in class II, 13.5% in class III, 33.3% in class IV, and 55.6% in class V., Conclusions: This prognostic classification may help direct triage decisions, assess appropriateness of care, and guide the design and analysis of therapeutic trials in patients with community-acquired pneumonia.