***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Proadrenomedullin ( ProADM ) confers additional prognostic information to established clinical risk scores in lower respiratory tract infections ( LRTI ) . We aim ed to derive a practical algorithm combining the CURB65 score with ProADM-levels in patients with community-acquired pneumonia ( CAP ) and non-CAP-LRTI . Methods We used data of 1359 patients with LRTI enrolled in a multicenter study . We chose two ProADM cut-off values by assessing the association between ProADM levels and the risk of adverse events and mortality . A composite score ( CURB65-A ) was created combining CURB65 classes with ProADM cut-offs to further risk-stratify patients . Results CURB65 and ProADM predicted both adverse events and mortality similarly well in CAP and non-CAP-LRTI . The combined CURB65-A risk score provided better prediction of death and adverse events than the CURB65 score in the entire cohort and in CAP and non-CAP-LRTI patients . Within each CURB65 class , higher ProADM-levels were associated with an increased risk of adverse events and mortality . Overall , risk of adverse events ( 3.9 % ) and mortality ( 0.65 % ) was low for patients with CURB65 score 0 - 1 and ProADM ≤0.75 nmol/l ( CURB65-A risk class I ) ; intermediate ( 8.6 % and 2.6 % , respectively ) for patients with CURB65 score of 2 and ProADM ≤1.5 nmol/l or CURB classes 0 - 1 and ProADM levels between 0.75 - 1.5 nmol/L ( CURB65-A risk class II ) , and high ( 21.6 % and 9.8 % , respectively ) for all other patients ( CURB65-A risk class III ) . If outpatient treatment was recommended for CURB65-A risk class I and short hospitalization for CURB65-A risk class II , 17.9 % and 40.8 % of 1217 hospitalized patients could have received ambulatory treatment or a short hospitalization , respectively . Conclusions The new CURB65-A risk score combining CURB65 risk classes with ProADM cut-off values accurately predicts adverse events and mortality in patients with CAP and non-CAP-LRTI . Additional prospect i ve cohort or intervention studies need to vali date this score and demonstrate its safety and efficacy for the management of patients with LRTI.Trial Registration Procalcitonin-guided antibiotic therapy and hospitalisation in patients with lower respiratory tract infections : the prohosp study ; is rct n.org Identifier : IS RCT N : IS RCT BACKGROUND Midregional proadrenomedullin ( MR-proADM ) is a potential prognostic biomarker in patients with community-acquired pneumonia ( CAP ) . Previous work has been hampered by sample size and illness spectrum limits . We sought to describe the pattern of MR-proADM in a broad CAP cohort , confirm its prognostic role , and compare its performance to procalcitonin , a novel biomarker of infection . METHODS We conducted a multicenter prospect i ve cohort study in 28 community and teaching EDs . Patients with a clinical and radiographic diagnosis of CAP were enrolled . We stratified MR-proADM levels a priori into quartiles and quantified severity of illness using the pneumonia severity index ( PSI ) ; and confusion ( abbreviated mental test score of < or= 8) , urea > or= 7 mmol/L , respiratory rate > or= 30 breaths/min , BP < 90 mm Hg systolic or < 60 mm Hg diastolic , age > or= 65 years ( CURB-65 ) . The primary outcome was 30-day mortality . RESULTS A total of 1,653 patients formed the study cohort .  MR-proADM levels consistently rose with PSI class and 30-day mortality ( p < 0.001 ) . MR-proADM had a higher area under the curve for 30-day mortality than procalcitonin ( 0.76 vs 0.65 , respectively ; p < 0.001 ) , but adding MR-proADM to the PSI in all subjects minimally improved performance . Among low-risk subjects ( PSI classes I to III ) , mortality was low and did not differ by MR-proADM quartile . However , among high-risk subjects ( PSI class IV/V ; n = 546 ) , subjects in the highest MR-proADM quartile ( n = 232 ; 42 % ) had higher 30-day mortality than those in MR-proADM quartiles 1 to 3 ( 23 % vs 9 % , respectively ; p < 0.0001 ) . Similar results were seen with CURB-65 . MR-proADM and procalcitonin levels were generally concordant ; only 6 % of PSI class IV/V subjects in the highest MR-proADM quartile had very low procalcitonin levels ( < 0.1 ng/mL ) . CONCLUSIONS In our multicenter CAP cohort , MR-proADM levels correlate with increasing severity of illness and death . High MR-proADM levels offer additional risk stratification in high-risk CAP patients , but otherwise MR-proADM levels do not alter PSI-based risk assessment in most CAP patients Long-term outcomes in patients surviving community-acquired pneumonia ( CAP ) are still incompletely understood . This study investigates the association of clinical parameters and blood markers with long-term mortality . We prospect ively followed 877 CAP patients from a previous multicentre trial for 18 months follow-up and investigated all-cause mortality following hospital discharge . Overall mortality was 17.3 % ( 95 % CI 14.8–19.8 % ) with a 12.8 % ( 95 % CI 10.9–15.0 % ) mortality incidence rate per year . Initial risk assignment using the Pneumonia Severity Index was accurate during the 18 month follow-up . Multivariable regression models ( hazard ratio , 95 % CI ) design ated the following as independent risk factors for long-term mortality : male sex ( 1.7 , 1.2–2.5 ) ; chronic obstructive pulmonary disease ( 1.5 , 1.1–2.1 ) ; neoplastic disease ( 2.5 , 1.7–3.7 ) ; and highest quartile of peak pro-adrenomedullin level ( 3.3 , 1.7–6.2 ) . Initial presentation with temperature > 38.7 ° C ( 0.4 , 0.2–0.6 ) , chills ( 0.6 , 0.4–0.99 ) and highest quartile of the inflammatory marker C-reactive-protein ( 0.3 , 0.2–0.5 ) were independent protective factors . A weighted risk score based on these variables showed good discrimination ( area under receiver operating characteristic curve 0.78 , 95 % CI 0.74–0.82 ) . Pronounced clinical and laboratory signs of systemic inflammatory host response upon initial hospital stay were associated with favourable long-term prognosis . Further studies should address whether closer monitoring of high-risk CAP patients after hospital discharge favourably impacts long-term mortality Background : In the assessment of severity in community acquired pneumonia ( CAP ) , the modified British Thoracic Society ( mBTS ) rule identifies patients with severe pneumonia but not patients who might be suitable for home management . A multicentre study was conducted to derive and vali date a practical severity assessment model for stratifying adults hospitalised with CAP into different management groups . Methods : Data from three prospect i ve studies of CAP conducted in the UK , New Zeal and , and the Netherl and s were combined . A derivation cohort comprising 80 % of the data was used to develop the model . Prognostic variables were identified using multiple logistic regression with 30 day mortality as the outcome measure . The final model was tested against the validation cohort . Results : 1068 patients were studied ( mean age 64 years , 51.5 % male , 30 day mortality 9 % ) . Age ⩾65 years ( OR 3.5 , 95 % CI 1.6 to 8.0 ) and albumin < 30 g/dl ( OR 4.7 , 95 % CI 2.5 to 8.7 ) were independently associated with mortality over and above the mBTS rule ( OR 5.2 , 95 % CI 2.7 to 10 ) . A six point score , one point for each of Confusion , Urea > 7 mmol/l , Respiratory rate ⩾30/min , low systolic(<90 mm Hg ) or diastolic ( ⩽60 mm Hg ) Blood pressure ) , age ⩾65 years ( CURB-65 score ) based on information available at initial hospital assessment , enabled patients to be stratified according to increasing risk of mortality : score 0 , 0.7 % ; score 1 , 3.2 % ; score 2 , 3 % ; score 3 , 17 % ; score 4 , 41.5 % and score 5 , 57 % . The validation cohort confirmed a similar pattern . Conclusions : A simple six point score based on confusion , urea , respiratory rate , blood pressure , and age can be used to stratify patients with CAP into different management groups Biomarkers are useful in community-acquired pneumonia ( CAP ) . Recently , midregional ( MR ) proadrenomedullin ( proADM ) has been shown to be of potential prognostic use . We sought to determine whether this prognostic role depends on the cause of CAP . We conducted a prospect i ve cohort study of immunocompetent patients with CAP . Pneumonia Severity Index ( PSI ) and CURB-65 score ( confusion ( abbreviated mental test score of ≤8 ) , urea ≥7 mol·L−1 , respiratory rate ≥30 breaths·min−1 , blood pressure < 90 mmHg systolic or < 60 mmHg diastolic , and age ≥65 yrs ) , blood C-reactive protein , procalcitonin , MR-proADM , and microbiological studies were systematic ally performed . Patients were grouped as bacterial , viral/atypical and mixed CAP , and were followed up at 30 , 90 and 180 days , and 1 yr . We recruited 228 CAP patients . Identification of at least one pathogen was achieved in 155 ( 68 % ) patients . MR-proADM levels closely correlated with increasing severity scores , and showed an important predictive power for complications and short- and long-term mortality ( 1 yr ) . Its addition to PSI and CURB-65 significantly improved their prognostic accuracy . A MR-proADM cut-off of 0.646 nmol·L−1 identified 92 % of patients scored as PSI classes IV and V as high risk . MR-proADM outcome prediction power was not affected by different aetiologies . MR-proADM  has high short- and long-term prognostic accuracy , and increases the accuracy of clinical scores . The prognostic value of MR-proADM is not modified by different possible CAP aetiologies A representation and interpretation of the area under a receiver operating characteristic ( ROC ) curve obtained by the " rating " method , or by mathematical predictions based on patient characteristics , is presented . It is shown that in such a setting the area represents the probability that a r and omly chosen diseased subject is ( correctly ) rated or ranked with greater suspicion than a r and omly chosen non-diseased subject . Moreover , this probability of a correct ranking is the same quantity that is estimated by the already well-studied nonparametric Wilcoxon statistic . These two relationships are exploited to ( a ) provide rapid closed-form expressions for the approximate magnitude of the sampling variability , i.e. , st and ard error that one uses to accompany the area under a smoothed ROC curve , ( b ) guide in determining the size of the sample required to provide a sufficiently reliable estimate of this area , and ( c ) determine how large sample sizes should be to ensure that one can statistically detect differences in the accuracy of diagnostic techniques Concerns about inadequate performance and complexity limit routine use of clinical risk scores in lower respiratory tract infections . Our aim was to study feasibility and effects of adding the biomarker proadrenomedullin ( proADM ) to the confusion , urea > 7 mmol·L−1 , respiratory rate ≥30 breaths·min−1 , blood pressure < 90 mmHg ( systolic ) or ≤60 mmHg ( diastolic ) , age ≥65 years ( CURB-65 ) score on triage decisions and length of stay . In a r and omised controlled proof-of-concept intervention trial , triage and discharge decisions were made for adults with lower respiratory tract infection according to interprofessional assessment using medical and nursing risk scores either without ( control group ) or with ( proADM group ) knowledge of proADM values , measured on admission , and on days 3 and 6 . An adjusted generalised linear model was calculated to investigate the effect of our intervention . On initial presentation the algorithms were overruled in 123 ( 39.3 % ) of the cases . Mean length of stay tended to be shorter in the proADM ( n=154 , 6.3 days ) compared with the control group ( n=159 , 6.8 days ; adjusted regression coefficient -0.19 , 95 % CI -0.41–0.04 ; p=0.1 ) . This trend was robust in subgroup analyses and for overall length of stay within 90 days ( 7.2 versus 7.9 days ; adjusted regression coefficient -0.18 , 95 % CI - 
    Output:
    
Conclusion : Elevated level of MR-proADM is significantly associated with both short-term mortality and complications in patients with CAP .
Studies also indicate that MR-proADM has prognostic value for prediction of long-term mortality in these patients .
The addition of MR-proADM improves the discriminant ability of CURB-65/CRB-65