BMJ:加测CRP有助预测肺炎

2013-05-27 青楚 医学论坛网

  欧洲一项多国联合研究显示,因急性咳嗽就诊于初级医疗卫生保健机构的患者,据其症状和体征即可较好预测罹患肺炎的可能;增加C反应蛋白(CRP)测定(阈值>30 mg/L)可提高诊断准确性,但增加降钙素原检测无此作用。论文4月30日在线发表于《英国医学杂志》(BMJ)。   该研究纳入了2007-2010年间就诊于初级医疗卫生保健机构的成年急性咳嗽患者2820例,据患者症状、体征及首诊时检

  欧洲一项多国联合研究显示,因急性咳嗽就诊于初级医疗卫生保健机构的患者,据其症状和体征即可较好预测罹患肺炎的可能;增加C反应蛋白(CRP)测定(阈值>30 mg/L)可提高诊断准确性,但增加降钙素原检测无此作用。论文4月30日在线发表于《英国医学杂志》(BMJ)。

  该研究纳入了2007-2010年间就诊于初级医疗卫生保健机构的成年急性咳嗽患者2820例,据患者症状、体征及首诊时检测CRP和降钙素原结果预测肺炎,并与7日内胸片结果进行比对。

  结果显示,预测肺炎的最佳临床项目组合为:无流涕、有呼吸困难、听诊闻及湿音及呼吸音减弱、心动过速、发热,此时接受者操作特征(ROC)曲线下面积为0.70;增加CRP>30 mg/L,ROC曲线下面积增至0.77。

Use of serum C reactive protein and procalcitonin concentrations in addition to symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough: diagnostic study.
OBJECTIVES
To quantify the diagnostic accuracy of selected inflammatory markers in addition to symptoms and signs for predicting pneumonia and to derive a diagnostic tool.
DESIGN
Diagnostic study performed between 2007 and 2010. Participants had their history taken, underwent physical examination and measurement of C reactive protein (CRP) and procalcitonin in venous blood on the day they first consulted, and underwent chest radiography within seven days.
SETTING
Primary care centres in 12 European countries.
PARTICIPANTS
Adults presenting with acute cough.
MAIN OUTCOME MEASURES
Pneumonia as determined by radiologists, who were blind to all other information when they judged chest radiographs.
RESULTS
Of 3106 eligible patients, 286 were excluded because of missing or inadequate chest radiographs, leaving 2820 patients (mean age 50, 40% men) of whom 140 (5%) had pneumonia. Re-assessment of a subset of 1675 chest radiographs showed agreement in 94% (κ 0.45, 95% confidence interval 0.36 to 0.54). Six published "symptoms and signs models" varied in their discrimination (area under receiver operating characteristics curve (ROC) ranged from 0.55 (95% confidence interval 0.50 to 0.61) to 0.71 (0.66 to 0.76)). The optimal combination of clinical prediction items derived from our patients included absence of runny nose and presence of breathlessness, crackles and diminished breath sounds on auscultation, tachycardia, and fever, with an ROC area of 0.70 (0.65 to 0.75). Addition of CRP at the optimal cut off of >30 mg/L increased the ROC area to 0.77 (0.73 to 0.81) and improved the diagnostic classification (net reclassification improvement 28%). In the 1556 patients classified according to symptoms, signs, and CRP >30 mg/L as "low risk" (<2.5%) for pneumonia, the prevalence of pneumonia was 2%. In the 132 patients classified as "high risk" (>20%), the prevalence of pneumonia was 31%. The positive likelihood ratio of low, intermediate, and high risk for pneumonia was 0.4, 1.2, and 8.6 respectively. Measurement of procalcitonin added no relevant additional diagnostic information. A simplified diagnostic score based on symptoms, signs, and CRP >30 mg/L resulted in proportions of pneumonia of 0.7%, 3.8%, and 18.2% in the low, intermediate, and high risk group respectively.
CONCLUSIONS
A clinical rule based on symptoms and signs to predict pneumonia in patients presenting to primary care with acute cough performed best in patients with mild or severe clinical presentation. Addition of CRP concentration at the optimal cut off of >30 mg/L improved diagnostic information, but measurement of procalcitonin concentration did not add clinically relevant information in this group.

作者:青楚



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