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The health care-associated pneumonia (HCAP) criteria have a limited ability to predict pneumonia caused by drug-resistant bacteria and favor the overutilization of broad-spectrum antibiotics. We aimed to derive and validate a clinical prediction score with an improved ability to predict the risk of pneumonia due to drug-resistant pathogens compared to that of HCAP criteria. A derivation cohort of 200 microbiologically confirmed pneumonia cases in 2011 and 2012 was identified retrospectively. Risk factors for pneumonia due to drug-resistant pathogens were evaluated by logistic regression, and a novel prediction score (the drug resistance in pneumonia [DRIP] score) was derived. The score was then validated in a prospective, observational cohort of 200 microbiologically confirmed cases of pneumonia at four U.S. centers in 2013 and 2014. The DRIP score (area under the receiver operator curve [AUROC], 0.88 [95% confidence interval {CI}, 0.82 to 0.93]) performed significantly better ( P = 0.02) than the HCAP criteria (AUROC, 0.72 [95% CI, 0.64 to 0.79]). At a threshold of ≥4 points, the DRIP score demonstrated a sensitivity of 0.82 (95% CI, 0.67 to 0.88), a specificity of 0.81 (95% CI, 0.73 to 0.87), a positive predictive value (PPV) of 0.68 (95% CI, 0.56 to 0.78), and a negative predictive value (NPV) of 0.90 (95% CI, 0.81 to 0.93). By comparison, the performance of HCAP criteria was less favorable: sensitivity was 0.79 (95% CI, 0.67 to 0.88), specificity was 0.65 (95% CI, 0.56 to 0.73), PPV was 0.53 (95% CI, 0.42 to 0.63), and NPV was 0.86 (95% CI, 0.77 to 0.92). The overall accuracy of the HCAP criteria was 69.5% (95% CI, 62.5 to 75.7%), whereas that of the DRIP score was 81.5% (95% CI, 74.2 to 85.6%) ( P = 0.005). Unnecessary extended-spectrum antibiotics were recommended 46% less frequently by applying the DRIP score (25/200, 12.5%) than by use of HCAP criteria (47/200, 23.5%) ( P = 0.004), without increasing the rate at which inadequate treatment recommendations were made. The DRIP score was more predictive of the risk of pneumonia due to drug-resistant pathogens than HCAP criteria and may have the potential to decrease antibiotic overutilization in patients with pneumonia. Validation in larger cohorts of patients with pneumonia due to all causes is necessary.

Rationale: Inspiratory muscle endurance as expressed by the tension-time index of the diaphragm [TTI=(Pdi/ Pdimax) × (Ti/Ttot)] in normal subjects and cardiorespiratory disorders requires the use of esophageal and gastric balloons. A noninvasive technique can be used in which the ratio of tidal volume to vital capacity (Vt/VC) is substituted for Pdi/Pdimax, with the resulting relationship [(Ti/Ttot) × (Vt/FVC)] called the breathing intolerance index (BIT). The response to medical management of BIT in patients with cardiomyopathy with chronic heartfailure has not been assessed before and after medical management. Objectives: To compare control of ventilation and BIT in patients with stable dilated cardiomyopathy at rest and exercise, and to analyze BIT, oxygen uptake and carbon dioxide elimination at baseline and approximately one year after initiating medical management. Methods: Control of ventilation and BIT were assessed in 24 patients (mean age 55.5 years; 17 males) at rest and at peak exercise during bicycle ergometry, at baseline and approximately 14 months later. Results: Median peak VO2 was 12.9 mL/kg/min and 14.3 mL/kg/min at baseline and followup, respectively (p

The term “linitis plastica” or leather-bottle stomach was introduced by William Brinton in 1858. This Greek eponym literally translates as “linen cloth” and refers to the characteristic fibrous proliferation noted on histology. Although largely accepted as a morphologic description of diffuse infiltrative gastric adenocarcinoma, the term linitis plastica is also used in the medical literature to describe the lesions caused by lye ingestion and diffuse gastric metastasis. Although less than 30 % of individuals with gastric cancer have signet-ring cell histology, it accounts for the majority of patients who present with linitis plastica [1]. Our case highlights the diagnostic difficulties associated with linitis plastica. In addition, it describes the rare association of diffuse signet-ring cell gastric adenocarcinoma and pernicious anemia and attempts to define a pathophysiologic correlation between the two.