RU2669401C1 - Method for predicting the occurrence of repeated community-acquired pneumonia in young men - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to diagnosis, and can be used to predict the development of repeated community-acquired pneumonia in a population of young men within the next 6 months after a previous “initial” community-acquired pneumonia. For this, after the end of pneumonia treatment, hemoglobin and ESR values are evaluated in the control blood test, and if the hemoglobin level is less than 140 g/l and the ESR index is more than 14 mm/h, then the increased risk of repeated community-acquired pneumonia is diagnosed within the next 6 months.EFFECT: method allows to effectively diagnose the risk of developing a community-acquired pneumonia by using the routine parameters of a general blood test.1 cl, 1 dwg, 2 tbl, 1 ex

Description

The invention relates to medicine, in particular to pulmonology, and can be used to identify in a patient who has had community-acquired pneumonia a high risk of developing repeated community-acquired pneumonia in the short term.

Community-acquired pneumonia (CAP) is one of the most common diseases in humans worldwide and is one of the leading causes of death among infectious diseases, and in Russia the highest mortality from CAP among adults is registered in men of working age (A. Chuchalin, A. Sinopalnikov. I., Kozlov RS Community-acquired pneumonia in adults: practical recommendations for diagnosis, treatment and prophylaxis. Moscow 2010, pp. 8-9).

N. Common variable immunodeficiency. Review. Allergol Immunopathol (Madr). 2001 May-Jun; 29(3):113-8.)Relapses of the disease (repeated pneumonia) are an additional serious medical and socio-economic problem for all countries, since they increase the risk of developing chronic lung diseases. Possible causes of recurrent (repeated) pneumonia are: aspiration of foreign material; bronchiectasis and other structural abnormalities; concomitant pathology, including infectious; immunological disorders that reduce the body's resistance to invasion of microorganisms into the pulmonary parenchyma, including General Variable Immunodeficiency Syndrome (AVIN) and a number of other factors (1. Eberlein M, Pearse D. B. A 56-Year-Old Man With Choking, Recurrent Pneumonia, and Weight Loss. Chest. 2007; 131 (4): 1248-1251. 2. Geppert EF. Chronic and recurrent pneumonia. Semin Respir Infect. 1992 Dec; 7 (4): 282-8. 3. Iglesias Alzueta J, Matamoros

N. Common variable immunodeficiency. Review Allergol Immunopathol (Madr). 2001 May-Jun; 29 (3): 113-8.)

Cases of iatrogenic causes of repeated pneumonia (Dang TT, Majumdar SR, Marrie TJ, Eurich DT. Recurrent pneumonia: a review with focus on clinical epidemiology and modifiable risk factors in elderly patients. Drugs Aging. 2015 Jan; 32 (1): 13- 9., Loke YK, Cavallazzi R, Singh S. Risk of fractures with inhaled corticosteroids in COPD: systematic review and metaanalysis of randomized controlled trials and observational studies. Thorax 2011 Aug; 66 (8): 699-708).

Since the occurrence of recurring community-acquired pneumonia (PVP) does not always require additional invasive studies, the examination of patients may not be complete, which may explain why the cause of recurrent pneumonia is not found in some cases (Brand PL, Hoving MF, de Groot EP. Evaluating the child with recurrent lower respiratory tract infections. Paediatr Respir Rev. 2012 Sep; 13 (3): 135-8. Epub 2011 Mar 4.).

Recently, researchers have been searching for markers that can predict the increased risk of repeated cases of pneumonia.

Viander M, He Q, Lokki ML, Ruuskanen О. C4A deficiency in children and adolescents with recurrent respiratory infections. Hum Immunol. 2012 May; 73(5):498-501. Epub 2012 Feb 26.).It has been established that age over 75 years and impaired respiratory function are risk factors for the development of repeated pneumonia within five years (Dang T.T. et al.). Risk factors for the development of PVP also include male gender, chronic obstructive pulmonary diseases, lack of vaccination for pneumococcal infection, and the use of acid-suppressing drugs. In the latter case, the risk of re-illness increases due to the acceleration of colonization and excessive growth of bacteria (Eurich DT, Sadowski S.A., Simpson SH, Marrie TJ Recurrent community acguired pneumonia in patients starting acid-supressing drugs. Am. J. Med .. - 2010. - V. 123. - No. 1. - P. 47-53.). Found genetic markers indicating a high risk of pneumonia and its relapse. Thus, a deficiency of the C4A gene, associated with a slight defect in immunity, can predispose children and young people to recurrent respiratory infections, and his study was proposed to be included in the list of diagnostic procedures in children with repeated pneumonia (Kainulainen L, Peltola V,

Viander M, He Q, Lokki ML, Ruuskanen O. C4A deficiency in children and adolescents with recurrent respiratory infections. Hum Immunol. 2012 May; 73 (5): 498-501. Epub 2012 Feb 26.).

Wheezing and a history of allergies, transient neutropenia may increase the risk of recurrence of pulmonary infection in children without concomitant diseases (Zhao YL, Liu ZJ, Wang YC. Risk factors for recurrent pneumonia in children: a case-control study. Zhongguo Dang Dai Er Ke Za Zhi. 2011 Dec; 13 (12): 962-5.). In children with anemia of different etiologies, cases of lower respiratory tract infections are more common. (Mourad S, Rajab M, Alameddine A, Fares M, Ziade F, Merhi BA. Hemoglobin level as a risk factor for lower respiratory tract infections in Lebanese children. N Am J Med Sci. 2010 Oct; 2 (10): 461- 466.).

Thus, in the patient populations of different age groups, different risk factors for repeated respiratory infection were noted. So, in children, such factors were: deficiency of the C4A gene, the presence of wheezing and a history of allergies, transient neutropenia, anemia (Kainulainen L. et al., Zhao Y.L. et al., Mourad S. et al.). In contrast, in elderly patients, the risk factors for re-pneumonia proved to be male, over 75 years old, chronic obstructive pulmonary diseases, impaired respiratory function, lack of vaccination for pneumococcal infection, the use of acid-suppressing drugs (Eurich DT et al., Dang TT et al.).

There are very few works aimed at identifying risk factors for re-pneumonia in populations of young men from organized groups. Single studies on a small contingent of patients (about 100 patients) showed that not only the first episode of pneumonia, but also PVP in military personnel is more often formed in the early stages of service and after an acute respiratory viral infection. (1. Grishchenko A.V., Lebedeva M.N. Pharmacoepidemiological analysis of the effectiveness of antibiotic therapy for repeated community-acquired pneumonia in conscript military personnel. Bulletin of medical Internet Conferences, (ISSN 2224-6150). (Volume 3, issue 6 P. 964- 966. http://www.medconfer.com/. 2. Lebedeva MH, Grishchenko AB Features of the course of repeated community-acquired pneumonia in conscript military personnel, Military Medical Journal, 2009, No. 7, pp. 24-27.) .

In general, the given risk factors for repeated pneumonia were found in groups of patients heterogeneous in age and sex and show their significant relationship with the age of patients. Thus, the data presented above in studies - analogues, therefore, cannot be used as a prognostic test in a separate population of young men from organized groups. In addition, the noted risk factors were not framed as the alleged invention or specific prognostic tests, had no technical solution. There was no quantitative assessment of the significance of such a possible forecasting. No testing was conducted on a separate additional sample of patients. Based on this, it can be concluded that a common drawback of analogues is the inability to use them for short-term prediction of the development of repeated pneumonia, including in the population of young men.

As one prototype, you can consider the "Method for predicting the development of postoperative pneumonia" authors VV Dubravina and O.A. Nazarova, consisting in the fact that predicting the development of pneumonia in adults immediately after surgery is carried out by summing up the severity (scores) of a number of clinical and laboratory symptoms that the patient has, and at certain values of this amount, an increased risk of developing pneumonia is diagnosed. The disadvantages of this method include the fact that it determines the risk of primary and not repeated pneumonia and that they assess the risk of pneumonia only in the early postoperative period - within a few days after the operation. The prototype provides for an additional in-depth examination of patients, which carries with it its cost and lengthening of time.

As another prototype, “Method for predicting acute pneumonia in setting large joint endoprostheses)) by Berdjugina O.V., Bazarnyj V.V., Berdjugin K.A. In this method, the increased risk of developing postoperative pneumonia is determined by the increased amount of cationic protein in blood neutrophils on day 2 after surgery.

The disadvantage of the prototype in comparison with the proposed method is also that it determines the increased risk of developing primary rather than repeated pneumonia and that the risk of pneumonia is assessed only in the early postoperative period - within a few days after surgery. The determination of cationic protein in leukocytes involves an additional examination of patients, which carries with it its cost.

The objective of the invention is to propose a method for short-term prediction of the occurrence of repeated community-acquired pneumonia in young men, a method that eliminates the cost of an additional examination of patients.

The technical result - the ability to predict with high probability in patients who have had community-acquired pneumonia, the development of repeated pneumonia in the period 6 months after the "initial" pneumonia without the use of additional examination methods.

The technical result is achieved by the fact that a patient is diagnosed with community-acquired pneumonia of mild course by eliminating community-acquired pneumonia of severe course (Clinical recommendations for the diagnosis, treatment and prevention of severe community-acquired pneumonia in adults. Russian Respiratory Society M. 2014. P. 14- 31). After completing the standard course of examination and treatment for 2-3 weeks and achieving clinical recovery with the disappearance of the radiological signs of pneumonia, a control general blood test is performed in accordance with medical standards before discharge. In this analysis, the hemoglobin level is first assessed. If it is below 140 g / l, the value of the erythrocyte sedimentation rate (ESR) is estimated. If the patient this indicator reaches 14 or more mm / hour, diagnosed with an increased risk of developing repeated pneumonia in the next 6 months.

In order to assess the quantitative significance of the hemoglobin and ESR values separately and when used together for short-term prediction of repeated VP, comparisons were made using the classical four-table table (Fletcher R., Fletcher S., Wagner A. Clinical epidemiology. Basics of evidence-based medicine Transl. From English. Media Sphere 1998, 347 pp.). Based on these data, in accordance with the principles and provisions of evidence-based medicine, the characteristics of the proposed test were calculated: sensitivity, specificity, prognostic value of positive and negative results, odds ratios.

A high probability of the development of suspected re-pneumonia within exactly 6 months after the “initial” pneumonia was revealed as a result of our specially conducted study of 141 patients with re-EP who were treated in 301 military clinical hospital (ICH) (Khabarovsk), its branch in the village . Anastasievka and 439 military hospital in Ussuriysk. The comparison group included 1396 patients of the same hospitals who underwent CAP without the subsequent development of PVP. The results of the study showed that the amount of PVP decreased exponentially in time, with 90.8% of all recurring pneumonias occurring in the first 6 months after the “primary” VP (Fig. 1). As a result of preliminary empirical analysis, we selected as the most promising indicator for creating a prognostic test the hemoglobin level in the control blood test before the patient is discharged from the hospital.

In the process of forming a prognostic test for the development of repeated VP when choosing a hemoglobin boundary level, we stopped at a value of 140 g / l. In patients of 301 VKG of Khabarovsk, in this case, the sensitivity of the test was 56.5%, specificity was 78.4%, and the odds ratio was 4.7. Checking the characteristics of these parameters in patients of the hospital village. Anastasievka, we found that sensitivity was 58.3%, specificity 60.0%, and odds ratios 2.1. In patients of the hospital in Ussuriysk, the sensitivity was 63.3%, the specificity was 57.9%, and the odds ratio was 2.2. Thus, in three unrelated contingents examined from different hospitals, the test parameters had values acceptable for practical use (R. Fletcher et al.).

In the combined group of patients of these hospitals, the studied parameters were also suitable for practical use. So, among patients with PVP, hemoglobin level of less than 140 g / l was in 41, and 140 and more g / l in 30 patients. In the group of patients without subsequent recurrence of CAP, a hemoglobin level of less than 140 g / l was found in 90, and 140 and more g / l in 330 patients (Table 1).

The sensitivity of this test was 58.6%, specificity 78.6%, and odds ratios 5.0. Such parameters are considered acceptable for practical use (R. Fletcher et al.).

Taking into account the low incidence of recurrence of EP among our population (more than 1,500 patients) - about 2%, which significantly reduced the prognostic value of positive test values, we calculated the recurrence rate for patients with blood hemoglobin level less than 140 g when discharged from hospitals / l An additional prognostic test was used for this category of patients in whom the frequency of recurrent CAP was already a priori 11.6%. It was formed according to an empirically selected indicator - the ESR level before discharge of patients from hospital 301 VKG with a “primary” EP and a reduced level of hemoglobin. As the boundary value, we chose the ESR level of 14 mm / hour. Of 113 patients with CAP with reduced hemoglobin level, 43 were diagnosed with PVP. An ESR level of 14 mm / hour and more was recorded in 22 of them, and less than 14 mm / hour in 21. In patients with reduced hemoglobin, but without repeated pneumonia, an ESR value of 14 and higher was found in 17, and less than 14 mm / hour - in 53 patients (tab. 2).

The sensitivity of this test was 51.2%, specificity - 75.7%. The odds ratios for a positive diagnosis were 2.1, and the odds ratios for eliminating relapse were 0.65.

According to calculations based on the data presented in the monograph by R. Fletcher et al., With the prevalence of recurrence of EP in this group equal to 1/9 and the values of sensitivity and specificity found, the prognostic value of a positive test result was already about 20% (R. Fletcher et al. ) This result indicates the likelihood of recurring VP in every fifth patient with a positive test result (a combination of hemoglobin values less than 140 and ESR more than 14 mm / hour.)

Thus, the advantage of the proposed method in comparison with the prototypes is that its implementation is not associated with any additional costs, since the routine parameters of the general blood test are used, which are part of the mandatory standard for examining all patients with diseases of the internal organs. The novelty of the method also lies in the combined use of two independent indicators of a blood test: hemoglobin level and ESR value.

Example 1

The effectiveness of the developed test was tested on a separate sample of 49 patients from the military hospital in Ussuriysk who underwent “early” PVP and in 101 patients without the development of PVP. The diagnostic test for this group of patients showed its relatively low sensitivity - 47%, quite high specificity - 84% and acceptable indicators of likelihood ratios - odds ratios - 3.1.

Considering that the high specificity of the test from the point of view of targeted application of rehabilitation measures and prevention of recurrence of VP in patients is more significant than its sensitivity (R. Fletcher et al.), We considered the above test results satisfactory.

In this regard, there is reason to recommend additional measures for the rehabilitation and prevention of recurrence of CAP for all patients of the above contingent (CAP patients with military service) who have the above-mentioned changes in the hemogram upon discharge from the hospital (hemoglobin less than 140 g / l in combination with ESR, exceeding 13 mm / hour).

Claims (1)

A method for predicting recurring community-acquired pneumonia in a population of young men, characterized in that after the treatment of pneumonia in the control blood test, hemoglobin and ESR are evaluated, and if the hemoglobin level is less than 140 g / l, and the ESR is 14 or more mm / hour, diagnosed increased risk of re-pneumonia over the next 6 months.

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