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Diagnostic utility of appetite loss in addition to existing prediction models for community-acquired pneumonia in the elderly: a prospective diagnostic study in acute care hospitals in Japan.

Diagnostic utility of appetite loss in addition to existing prediction models for community-acquired pneumonia in the elderly: a prospective diagnostic study in acute care hospitals in Japan.
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Takada T, Yamamoto Y, Terada K, Ohta M, Mikami W, Yokota H, Hayashi M, Miyashita J, Azuma T, Fukuma S, Fukuhara S,


Takada T, Yamamoto Y, Terada K, Ohta M, Mikami W, Yokota H, Hayashi M, Miyashita J, Azuma T, Fukuma S, Fukuhara S, (click to view)

Takada T, Yamamoto Y, Terada K, Ohta M, Mikami W, Yokota H, Hayashi M, Miyashita J, Azuma T, Fukuma S, Fukuhara S,

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BMJ open 2017 11 087(11) e019155 doi 10.1136/bmjopen-2017-019155
Abstract
OBJECTIVE
Diagnosis of community-acquired pneumonia (CAP) in the elderly is often delayed because of atypical presentation and non-specific symptoms, such as appetite loss, falls and disturbance in consciousness. The aim of this study was to investigate the external validity of existing prediction models and the added value of the non-specific symptoms for the diagnosis of CAP in elderly patients.

DESIGN
Prospective cohort study.

SETTING
General medicine departments of three teaching hospitals in Japan.

PARTICIPANTS
A total of 109 elderly patients who consulted for upper respiratory symptoms between 1 October 2014 and 30 September 2016.

MAIN OUTCOME MEASURES
The reference standard for CAP was chest radiograph evaluated by two certified radiologists. The existing models were externally validated for diagnostic performance by calibration plot and discrimination. To evaluate the additional value of the non-specific symptoms to the existing prediction models, we developed an extended logistic regression model. Calibration, discrimination, category-free net reclassification improvement (NRI) and decision curve analysis (DCA) were investigated in the extended model.

RESULTS
Among the existing models, the model by van Vugt demonstrated the best performance, with an area under the curve of 0.75(95% CI 0.63 to 0.88); calibration plot showed good fit despite a significant Hosmer-Lemeshow test (p=0.017). Among the non-specific symptoms, appetite loss had positive likelihood ratio of 3.2 (2.0-5.3), negative likelihood ratio of 0.4 (0.2-0.7) and OR of 7.7 (3.0-19.7). Addition of appetite loss to the model by van Vugt led to improved calibration at p=0.48, NRI of 0.53 (p=0.019) and higher net benefit by DCA.

CONCLUSIONS
Information on appetite loss improved the performance of an existing model for the diagnosis of CAP in the elderly.

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