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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Community acquired pneumonia &#40;CAP&#41; is considered a major problem of public health due to its high morbimortality&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> To a large extent&#44; mortality depends on the place where the patients are treated&#46; In outpatients&#44; the rate is less than 3&#37;&#44; in patients admitted to a conventional unit&#44; the rate ranges from 5 to 10&#37;&#44; whereas in those patients who require admission to an intensive care unit amounts to 25&#37; if they require orotracheal intubation and up to 50&#37; if they require vasopressors&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Most studies published to date have studied the relationship between pneumonia and short-term mortality&#46; However&#44; there are data indicating that patients who survive a pneumonia episode have a high mortality rate&#44; even in the medium and long term&#44; with figures of 8&#44; 21&#44; and 36&#37; after 90 days&#44; one year&#44; and five years&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Often&#44; an acute condition in older adults that requires hospitalization implies a subsequent clinical worsening&#46; This issue seems to be particularly frequent in patients suffering from pneumonia&#46; Kaplan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> assessed patients admitted for pneumonia and found that in-hospital mortality rate was the half in the control group compared with the CAP group&#46; One-year mortality after hospital discharge and adjusted for comorbidities was 33&#46;6&#37; among those patients who had been discharged with a diagnosis of CAP <span class="elsevierStyleItalic">versus</span> 24&#46;9&#37; in the control group without CAP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are several predictive factors of long-term mortality&#46; Numerous articles highlight age as one of the main predictors of mortality&#46; Indeed&#44; inflammation among elderly people should be assessed independently as it probably has a distinctive role&#46; What still remains to be clarified is the cut-off point at which age begins to be a risk factor&#46; The number of individuals aged over 65 years has increased in recent years and that number is expected to rise from 12&#37; in 2000 to 20&#37; in 2030&#44; and even reaching the double in 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In general&#44; the older adult population suffers from a greater number of comorbidities and the functional status is often poor&#46; In addition&#44; most studies point out that the male sex is associated with higher mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Similarly&#44; some authors found an alarming difference regarding race&#44; with increased 2-year mortality rate in black individuals compared with white individuals<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>&#46; Healthcare-associated-pneumonia has an increased risk of death&#44; mostly due to poor functional status&#44; advanced age&#44; treatment restrictions and high number of comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Pneumonia in these patients is usually caused by specific etiologies with a worse prognosis&#46; Little is known about the impact of different etiologies on long-term prognosis&#44; though&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple comorbidities&#44; such as cerebrovascular disease&#44; cardiovascular disease&#44; neoplasms&#44; HIV&#44; chronic obstructive respiratory disease&#44; and deterioration of the functional state&#44; have been associated with increased mortality in patients with CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;8</span></a> Moreover&#44; cardiovascular diseases seem to have elicited greater interest&#46; Several authors have suggested a higher incidence of cardiac complications after a CAP episode&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In this sense&#44; in a recent review&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> an increased incidence of cardiovascular events was found&#44; such as myocardial infarction&#44; arrhythmias&#44; and heart failure&#44; in patients suffering from pneumonia&#46; Systemic inflammation&#44; coronary artery inflammation&#44; platelet activation and thrombosis&#44; endothelial dysfunction&#44; and effects of CAP on the heart have been suggested as possible mechanisms for increased cardiovascular events following respiratory infections&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It seems that not only comorbidities have an impact on long-term mortality&#44; but also disease severity <span class="elsevierStyleItalic">per se</span> may have a role in long-term prognosis&#46; The majority of the scores created to date were intended to measure short-term complications but there are not specific tools to predict long-term mortality&#46; Recently&#44; CURB65 and PSI scores were assessed for long-term mortality in a six-year follow-up study and both showed excellent predictive accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> However&#44; several authors have demonstrated that PSI was better for predicting long-term mortality probably due to the inclusion of comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a> On the other hand&#44; severity prognostic scores are static clinical scores and lack information on the host inflammatory response&#46; The concomitant use of certain biomarkers could provide objective criteria to make decisions with respect to these patients&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the last years&#44; studies have been conducted with biomarkers of more cardiovascular profiles and found that proADM started gaining greater relevance&#46; Pro-ADM has demonstrated superiority over CRP and PCT to predict the mortality of these patients more accurately&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> This fact could be due to the cardiovascular activity of this biomarker in addition to its immunomodulatory and antimicrobial effects&#46; Cardiac conditions&#44; malignancies or neurological conditions have been postulated as underlying causes of death among patients after an episode of CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> However&#44; it is worth noting the transcendent role of cardiovascular diseases as main cause of medium- and long-term mortality in these patients&#46; Biomarkers can be of great utility to identify a persistent chronic inflammation state initiated after a CAP episode&#44; which can lead to the development of cardiovascular diseases&#46; Several authors suggest that high long-term mortality rate in patients with CAP could be due to a persistent inflammatory response after hospital discharge or even cardiovascular diseases that were not previously known and emerged after the episode&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; it seems clear that patients with CAP have increased mortality rates&#44; also in the long term&#46; However&#44; the influence that the interaction between acute episodes and the various comorbidities and conditions may exert should be assessed carefully&#46; Future research should include new specific tools to predict long-term mortality among these patients at high risk of death&#46; In this sense&#44; it would be of special interest to evaluate cardiovascular biomarkers levels in the follow-up after hospitalization with CAP in order to demonstrate if patients with less significant decreases over time have higher mortality rates&#46; This would support the idea that persistently elevated levels of biomarkers are associated with an increased risk of cardiovascular events&#46; Therefore&#44; close monitoring should be encouraged in order to optimize its management and&#44; undoubtedly&#44; improve its long-term prognosis&#46;</p></span>"
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Editorial
Long-term Mortality in Community-acquired Pneumonia
Mortalidad a largo plazo de la neumonía adquirida en la comunidad
Ane Uranga
Corresponding author
, Pedro Pablo España
Servicio de Neumología, Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Community acquired pneumonia &#40;CAP&#41; is considered a major problem of public health due to its high morbimortality&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> To a large extent&#44; mortality depends on the place where the patients are treated&#46; In outpatients&#44; the rate is less than 3&#37;&#44; in patients admitted to a conventional unit&#44; the rate ranges from 5 to 10&#37;&#44; whereas in those patients who require admission to an intensive care unit amounts to 25&#37; if they require orotracheal intubation and up to 50&#37; if they require vasopressors&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> Most studies published to date have studied the relationship between pneumonia and short-term mortality&#46; However&#44; there are data indicating that patients who survive a pneumonia episode have a high mortality rate&#44; even in the medium and long term&#44; with figures of 8&#44; 21&#44; and 36&#37; after 90 days&#44; one year&#44; and five years&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Often&#44; an acute condition in older adults that requires hospitalization implies a subsequent clinical worsening&#46; This issue seems to be particularly frequent in patients suffering from pneumonia&#46; Kaplan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> assessed patients admitted for pneumonia and found that in-hospital mortality rate was the half in the control group compared with the CAP group&#46; One-year mortality after hospital discharge and adjusted for comorbidities was 33&#46;6&#37; among those patients who had been discharged with a diagnosis of CAP <span class="elsevierStyleItalic">versus</span> 24&#46;9&#37; in the control group without CAP &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">There are several predictive factors of long-term mortality&#46; Numerous articles highlight age as one of the main predictors of mortality&#46; Indeed&#44; inflammation among elderly people should be assessed independently as it probably has a distinctive role&#46; What still remains to be clarified is the cut-off point at which age begins to be a risk factor&#46; The number of individuals aged over 65 years has increased in recent years and that number is expected to rise from 12&#37; in 2000 to 20&#37; in 2030&#44; and even reaching the double in 2050&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> In general&#44; the older adult population suffers from a greater number of comorbidities and the functional status is often poor&#46; In addition&#44; most studies point out that the male sex is associated with higher mortality rates&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Similarly&#44; some authors found an alarming difference regarding race&#44; with increased 2-year mortality rate in black individuals compared with white individuals<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a>&#46; Healthcare-associated-pneumonia has an increased risk of death&#44; mostly due to poor functional status&#44; advanced age&#44; treatment restrictions and high number of comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Pneumonia in these patients is usually caused by specific etiologies with a worse prognosis&#46; Little is known about the impact of different etiologies on long-term prognosis&#44; though&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple comorbidities&#44; such as cerebrovascular disease&#44; cardiovascular disease&#44; neoplasms&#44; HIV&#44; chronic obstructive respiratory disease&#44; and deterioration of the functional state&#44; have been associated with increased mortality in patients with CAP&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4&#44;8</span></a> Moreover&#44; cardiovascular diseases seem to have elicited greater interest&#46; Several authors have suggested a higher incidence of cardiac complications after a CAP episode&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In this sense&#44; in a recent review&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> an increased incidence of cardiovascular events was found&#44; such as myocardial infarction&#44; arrhythmias&#44; and heart failure&#44; in patients suffering from pneumonia&#46; Systemic inflammation&#44; coronary artery inflammation&#44; platelet activation and thrombosis&#44; endothelial dysfunction&#44; and effects of CAP on the heart have been suggested as possible mechanisms for increased cardiovascular events following respiratory infections&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">It seems that not only comorbidities have an impact on long-term mortality&#44; but also disease severity <span class="elsevierStyleItalic">per se</span> may have a role in long-term prognosis&#46; The majority of the scores created to date were intended to measure short-term complications but there are not specific tools to predict long-term mortality&#46; Recently&#44; CURB65 and PSI scores were assessed for long-term mortality in a six-year follow-up study and both showed excellent predictive accuracy&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> However&#44; several authors have demonstrated that PSI was better for predicting long-term mortality probably due to the inclusion of comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">8&#44;11&#44;12</span></a> On the other hand&#44; severity prognostic scores are static clinical scores and lack information on the host inflammatory response&#46; The concomitant use of certain biomarkers could provide objective criteria to make decisions with respect to these patients&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the last years&#44; studies have been conducted with biomarkers of more cardiovascular profiles and found that proADM started gaining greater relevance&#46; Pro-ADM has demonstrated superiority over CRP and PCT to predict the mortality of these patients more accurately&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> This fact could be due to the cardiovascular activity of this biomarker in addition to its immunomodulatory and antimicrobial effects&#46; Cardiac conditions&#44; malignancies or neurological conditions have been postulated as underlying causes of death among patients after an episode of CAP&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> However&#44; it is worth noting the transcendent role of cardiovascular diseases as main cause of medium- and long-term mortality in these patients&#46; Biomarkers can be of great utility to identify a persistent chronic inflammation state initiated after a CAP episode&#44; which can lead to the development of cardiovascular diseases&#46; Several authors suggest that high long-term mortality rate in patients with CAP could be due to a persistent inflammatory response after hospital discharge or even cardiovascular diseases that were not previously known and emerged after the episode&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; it seems clear that patients with CAP have increased mortality rates&#44; also in the long term&#46; However&#44; the influence that the interaction between acute episodes and the various comorbidities and conditions may exert should be assessed carefully&#46; Future research should include new specific tools to predict long-term mortality among these patients at high risk of death&#46; In this sense&#44; it would be of special interest to evaluate cardiovascular biomarkers levels in the follow-up after hospitalization with CAP in order to demonstrate if patients with less significant decreases over time have higher mortality rates&#46; This would support the idea that persistently elevated levels of biomarkers are associated with an increased risk of cardiovascular events&#46; Therefore&#44; close monitoring should be encouraged in order to optimize its management and&#44; undoubtedly&#44; improve its long-term prognosis&#46;</p></span>"
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