Comparative impact of morbid obesity vs heart failure on cardiorespiratory fitness

BACKGROUND: We are in the midst of an obesity pandemic. Morbid obesity is associated with dyspnea on exertion and higher overall mortality rates. The relations between measures of cardiorespiratory fitness in morbidly obese persons compared to those with heart failure are unknown. METHODS: We compared cardiorespiratory fitness in patients with morbid obesity (n = 43) and established systolic dysfunction heart failure (n = 235), and in age-matched medical control subjects (n = 222) who had been referred for diagnostic exercise testing with simultaneous metabolic measurements. Only patients who completed an adequate test for maximum exertion manifested by a respiratory exchange ratio of > or = 1.10 were included in the study. RESULTS: The mean (+/- SD) body mass index (BMI) values for the three groups were 47.8 +/- 5.1, 30.1 +/- 5.7, and 33.8 +/- 9.0, respectively (p < 0.0001 for comparisons between morbidly obese patients and each comparator). The mean left ventricular ejection fraction for the heart failure group was 21.5 +/- 8.4%. Despite achieving higher peak heart rate and BP values, the morbidly obese patients had a mean maximum oxygen uptake (V(O2)max) that was similar to that of those with heart failure (17.8 +/- 3.6 vs 16.5 +/- 5.6 mL/kg/min, respectively; p = 0.14) and was considerably lower than that of the control group (17.8 +/- 3.6 vs 21.3 +/- 8.2 mL/kg/min, respectively; p = 0.007). In addition, among subjects in the control group, there was a graded inverse relation between BMI and V(O2)max. CONCLUSIONS: Morbidly obese individuals have severely reduced cardiorespiratory fitness that is similar to those with established systolic dysfunction heart failure. In addition, in those persons who are referred for stress testing for medical reasons, there is an inverse graded relationship between BMI and cardiorespiratory fitness. These data suggest that the impairment in V(O2)max in morbidly obese persons is related to BMI and possibly to other factors that impair peak cardiac performance. These findings are consistent with overall higher expected mortality in morbidly obese persons.     

Lymphangioleiomyomatosis: a clinical update

Lymphangioleiomyomatosis (LAM) is a rare, cystic lung disease that is associated with mutations in tuberous sclerosis genes, renal angiomyolipomas, lymphatic spread, and remarkable female gender restriction. The clinical course of LAM is characterized by progressive dyspnea on exertion, recurrent pneumothorax, and chylous fluid collections. Lung function declines at approximately twofold to threefold times the rate of healthy subjects, based on an annual drop in FEV1 of 75 to 120 mL in reported series. The diagnosis of pulmonary LAM can be made on high-resolution CT (HRCT) scan with reasonable certainty by expert radiologists, but generally requires a lung biopsy in cases in which tuberous sclerosis complex, angiomyolipomata, or chylous effusions are absent. The currently available treatment strategies are based on the antagonism of estrogen action, and are empiric and unproven. A trial of bronchodilators is warranted in patients with reversible airflow obstruction seen on pulmonary function testing. Pleurodesis should be performed with the initial pneumothorax, because the rate of recurrence is high. Angiomyolipomas that exceed 4 cm in size are more likely to bleed and should be evaluated for embolization. Air travel is well-tolerated by most patients with LAM. Lung transplantation is an important option for LAM patients, and can be safely performed by experienced surgeons despite prior unilateral or bilateral pleurodesis in most patients. Women with unexplained recurrent pneumothorax, tuberous sclerosis, or a diagnosis of primary spontaneous pneumothorax or emphysema in the setting of limited or absent tobacco use should undergo HRCT scan screening for LAM. Multicenter clinical trials based on several well-defined molecular targets are currently underway in the United States and Europe.     

FEV1 performance among patients with acute asthma: results from a multicenter clinical trial

OBJECTIVE: To determine the ability of patients seen for acute asthma exacerbations in the emergency department (ED) to perform good-quality FEV(1) measurements. METHODS: Investigators from 20 EDs were trained to perform spirometry testing as part of a clinical trial that included standardized equipment with special software-directed prompts. Spirometry was done on ED arrival and 30 min, 1 h, 2 h, and 4 h later, and during follow-up outpatient visits. MEASUREMENTS: Study performance criteria differed from American Thoracic Society (ATS) guidelines because of the population acuity and severity of illness as follows: ability to obtain acceptable FEV(1) measures (defined as two or more efforts with forced expiratory times >/= 2 s and time to peak flow < 120 ms or back-extrapolated volume < 5% of the FVC) and reproducibility criteria (two highest acceptable FEV(1) values within 10% of each other). RESULTS: Of the 620 patients (age range, 12 to 65 years), > 90% met study acceptability criteria on ED arrival and 74% met study reproducibility criteria. Mean initial FEV(1) was 38% of predicted. Spirometry quality improved over time; by 1 h, 90% of patients met study acceptability and reproducibility criteria. Patients with severe airway obstruction (FEV(1) < 25% of predicted) were initially less likely to meet quality goals, but this improved with time. The site was also an independent predictor of quality. CONCLUSION: When staff are well trained and prompt feedback regarding adequacy of efforts is given, modified ATS performance goals for FEV(1) tests can be met from most acutely ill adolescent and adult asthmatics, even within the first hour of evaluation and treatment for an asthma exacerbation.     

Treatment adherence and outcomes in flexible vs standard continuous positive airway pressure therapy

STUDY OBJECTIVES: To compare adherence and clinical outcomes between flexible positive airway pressure (PAP) [C-Flex; Respironics; Murraysville, PA] and standard PAP therapy (ie, continuous positive airway pressure [CPAP]). DESIGN AND SETTING: A controlled clinical trial of CPAP therapy vs therapy using the C-Flex device in participants with moderate-to-severe obstructive sleep apnea. Participants were recruited from and followed up through an academic sleep disorders center. PARTICIPANTS: Eighty-nine participants were recruited into the study after they had undergone complete in-laboratory polysomnography and before initiating therapy. Participants received either therapy with CPAP (n = 41) or with the C-Flex device (n = 48), depending on the available treatment at the time of recruitment, with those recruited earlier receiving CPAP therapy and those recruited later receiving therapy with the C-Flex device. Follow-up assessments were conducted at 3 months. MEASUREMENTS AND RESULTS: The groups were similar demographically. The mean (+/- SD) treatment adherence over the 3-month follow-up period was higher in the C-Flex group compared to the CPAP group (weeks 2 to 4, 4.2 +/- 2.4 vs 3.5 +/- 2.8, respectively; weeks 9 to 12, 4.8 +/- 2.4 vs 3.1 +/- 2.8, respectively). Clinical outcomes and attitudes toward treatment (self-efficacy) were also measured. Change in subjective sleepiness and functional outcomes associated with sleep did not improve more in one group over the other. Self-efficacy showed a trend toward being higher at the follow-up in those patients who had been treated with the C-Flex device compared to CPAP treatment. CONCLUSIONS: Therapy with the C-Flex device may improve overall adherence over 3 months compared to standard therapy with CPAP. Clinical outcomes do not improve consistently, but C-Flex users may be more confident about their ability to adhere to treatment. Randomized clinical trials are needed to replicate these findings.     

Follow-up of asymptomatic pancreatic cysts in clinical practice: A vignette questionnaire

Background/ObjectivesIn absence of evidence-based guidelines of pancreatic cystic neoplasms (PCN), the management might vary among physicians. The aim of this survey was to assess the attitude of Dutch gastroenterologists (GE) towards the management of asymptomatic PCNs.MethodsAn anonymous online questionnaire was distributed to all practicing GE (n = 381) in The Netherlands, in which four vignette patients with PCN were presented.ResultsIn total 45% of GE responded. Most respondents would perform surveillance for a 10 mm PCN (78%) mainly with an interval of one year (57%). A shorter interval of three (26%) or six (57%) months was chosen for a 25 mm BD-IPMN. Ultrasound was recommended for surveillance by 19% for a 10 mm cyst. GE with EUS experience were more likely to apply EUS for surveillance of 10 mm cyst than those without (56% vs 28%; p < 0.001). The presence of a branch-duct intraductal mucinous neoplasm (BD-IPMN) with a mural nodule, dilated pancreatic duct (8 mm) or increased serum CA 19.9 (300 U/ml) were considered an indication for resection by respectively 88%, 68% and 51% of respondents.ConclusionDutch GE demonstrate substantial variability in the management of asymptomatic PCNs. A significant proportion of general GE still use ultrasound for surveillance of small PCNs, while GE with EUS experience were more likely to perform EUS. The presence of risk factors for malignant degeneration of IPMN were not recognized by a substantial proportion of GE. Data on the natural history of PCNs is required to provide input for evidence-based guidelines, which should lead to a more uniform approach.     

The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge: a long-term follow-up study

BACKGROUND: The time course of changes in health-related quality of life (HRQOL) following discharge from the ICU and during a general ward stay has not been studied. We therefore studied the immediate impact of critical illness on HRQOL and its recovery over time. METHODS: In a prospective study, all patients admitted to the ICU for > 48 h who ultimately survived to follow-up at 6 months were included. The Medical Outcomes Study 36-item short form was used to measure HRQOL before ICU admission, at discharge from the ICU and hospital, and at 3 and 6 months following discharge from the ICU and hospital. An age-matched healthy Dutch population was used as a reference. RESULTS: Of the 451 included patients, 252 could be evaluated at 6 months (40 were lost to follow-up, and 159 died). Pre-ICU admission HRQOL in survivors was significantly worse compared to the healthy population. Patients who died between ICU admission and long-term follow-up had significantly worse HRQOL in all dimensions already at ICU admission when compared to the long-term survivors. HRQOL decreased in all dimensions (p < 0.001) during ICU stay followed by a rapid improvement during hospital stay, gradually improving to near pre-ICU admission HRQOL at 6 months following ICU discharge. Physical functioning (PF), general health (GH), and social functioning (SF) remained significantly lower than pre-ICU admission values. Compared to the healthy Dutch population, ICU survivors had significantly lower HRQOL 6 months following ICU discharge (except for the bodily pain score). CONCLUSIONS: A sharp multidimensional decline in HRQOL occurs during ICU admission where recovery already starts following ICU discharge to the general ward. Recovery is incomplete for PF, GH, and SF when compared to baseline values and the healthy population.     

Twice vs three times daily heparin dosing for thromboembolism prophylaxis in the general medical population: A metaanalysis

OBJECTIVES: Prophylaxis with unfractionated heparin (UFH) has been proven to reduce rates of venous thromboembolism (VTE) in hospitalized medical patients. While twice-daily (BID) and three-times-daily (TID) dosing regimens have been studied, the two have never been directly compared. We performed a metaanalysis to assess whether TID is superior to BID dosing in the prevention of VTE. METHODS: Medline, EMBASE, and Cochrane Controlled Trials Register from 1966 through December 2004 were searched for randomized trials comparing subcutaneously dosed UHF (either BID or TID) with placebo or control for VTE prophylaxis in medical patient populations. Two reviewers independently rated study quality on the basis of predetermined criteria. Data were extracted on patient age, hospital setting, comorbidities, VTE rates, and bleeding complications. RESULTS: Twelve studies were identified; 7,978 patients (1,664 patients in the TID arm, and 6,314 patients in the BID arm) were included. After adjustment for baseline risk, there was no difference in the overall rate (per 1,000 patient-days) of VTE (BID, 5.4; vs TID, 3.5; p = 0.87). TID heparin showed a trend toward a decrease in pulmonary embolism (PE) [BID, 1.5; vs TID, 0.5; p = 0.09] and in proximal DVT and PE (BID, 2.3; vs TID, 0.9; p = 0.05). The risk for major bleeding was significantly increased with TID heparin (BID, 0.35; vs TID, 0.96; p < 0.001). CONCLUSIONS: BID heparin dosing causes fewer major bleeding episodes, while TID dosing appears to offer somewhat better efficacy in preventing clinically relevant VTE events. Practitioners should use underlying risk for VTE and bleeding to individualize pharmacologic prevention.     

Ventilator-associated pneumonia: impact of organisms on clinical resolution and medical resources utilization

BACKGROUND: Clinical resolution of ventilator-associated pneumonia (VAP) determines the duration of treatment and mechanical ventilation. The aim of this study was to evaluate the influence of organisms and their susceptibility to treatment on outcomes. METHODS: Prospective observational study in three teaching ICUs. Sixty episodes of VAP with appropriate therapy (Haemophilus influenzae, 15 episodes; methicillin-sensitive Staphylococcus aureus [MSSA], 15 episodes; Pseudomonas aeruginosa, 15 episodes; and methicillin-resistant S aureus [MRSA], 15 episodes), and 30 episodes with initial inappropriate therapy, all due to P aeruginosa, were compared. The main outcome measures were clinical resolution variables and, in survivors, length of mechanical ventilation after VAP onset. RESULTS: A significant delay in the resolution of hypoxemia was observed in VAP episodes due to MRSA and P aeruginosa with inappropriate antibiotic therapy (IAT) (median time to resolution, 10 and 8 days, respectively) when compared with the remaining pathogens (median time to resolution, 2 days). A multiple regression model, adjusted for disease severity, confirmed the delayed clinical resolution for MRSA and P aeruginosa with IAT. Similar associations were documented for defervescence. Among survivors, the median duration of mechanical ventilation after VAP onset was significantly longer for MRSA (17 days) and P aeruginosa IAT (11 days) when compared with episodes due to H influenzae or MSSA (6 days). Multiple regression analysis, adjusted for disease severity, confirmed that MRSA required significantly (R(2) = 0.132; p < 0.01) longer respiratory support than other organisms. CONCLUSIONS: When treated promptly, the resolution of VAP due to MSSA, H influenzae, and P aeruginosa was comparable. The resolution of MRSA VAP, regardless of the appropriateness of initial antibiotic therapy, was associated with longer respiratory support.     

Prevalence and risks of chronic airway obstruction: a population cohort study in taiwan

BACKGROUND: This study investigated the prevalence, incidence, and hospitalization for chronic airway obstruction (CAO) in a population cohort. METHODS: Medical reimbursement claims from 1996 to 2002 based on a 1996 insured cohort of 167,372 persons from National Health Insurance, Taiwan, were used. We presented the chronological trends of CAO (International Classification of Diseases, Ninth Revision code 496) and the relationships between the CAO severity and age, sex, urbanization, and hospitalization and comorbidity for the population >/= 40 years old. RESULTS: The overall average annual prevalence and incidence rates were 2.48/100 and 0.66/100, respectively, for the population, among 4,568 patients with CAO cared during the study period. For the population aged >/= 70 years, the prevalence rates had a peak of 8.83/100 in 1998 and afterward remained a plateau until 2002. The corresponding incidence decreased from 2.48/100 to 1.62/100, and the hospitalization rate for them had a peak of 2.22/100 in 1999. The multivariate logistic regression analysis showed that the risk of hospitalization for CAO was higher for patients with the comorbidity of renal failure, coronary artery disease, and pneumonia and influenza, but lower with skin and joint disorders. CONCLUSIONS: The national insurance program promotes patient care and provides a proper pathway for surveillance and identification of CAO.     

Ventilator-associated tracheobronchitis: the impact of targeted antibiotic therapy on patient outcomes

Nosocomial lower respiratory tract infections are a common cause of morbidity and mortality in ICU patients receiving mechanical ventilation. Many studies have investigated the management and prevention of ventilator-associated pneumonia (VAP), but few have focused on the role of ventilator-associated tracheobronchitis (VAT). The pathogenesis of lower respiratory tract infections often begins with tracheal colonization that may progress to VAT, and in selected patients to VAP. Since there is no well-established definition of VAT, discrimination between VAT and VAP can be challenging. VAT is a localized disease with clinical signs (fever, leukocytosis, and purulent sputum), microbiologic information (Gram stain with bacteria and leukocytes, with either a positive semiquantitative or a quantitative sputum culture), and the absence of a new infiltrate on chest radiograph. Monitoring endotracheal aspirates has been used to identify and quantify pathogens colonizing the lower airway, to diagnose VAT or VAP, and to initiate early, targeted antibiotic therapy. Recent data suggest that VAT appears to be an important risk factor for VAP and that targeted antibiotic therapy for VAT may be a new paradigm for VAP prevention and better patient outcomes.     

Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy

CONTEXT: A growing body of reports has documented the ability of anticoagulation management services to help patients receiving warfarin therapy achieve better outcomes compared to the care provided by their personal physicians (ie, usual care). OBJECTIVE: To compare clinical outcomes associated with anticoagulation therapy provided by a clinical pharmacy anticoagulation service (CPAS) to usual care. DESIGN: Retrospective, observational cohort study, 6 months in duration. SETTING: Large nonprofit, group-model health maintenance organization. PATIENTS: A total of 6,645 patients receiving warfarin therapy were included in the final analyses (intervention group, 3,323 patients; control group, 3,322 patients). INTERVENTION: Anticoagulation therapy for patients in the intervention group was managed by a centralized, telephonic CPAS. Therapy for patients in the control group was managed in the usual manner by their personal physicians. MAIN OUTCOME MEASURES: The primary outcome was the occurrence of anticoagulation therapy-related complications. A secondary outcome was the proportion of time spent in the target international normalized ratio (INR) range for each patient. Cox proportional hazards regression analyses were used to examine the risk of complications in relation to the study group. RESULTS: Patients in the CPAS were 39% less likely to experience an anticoagulation therapy-related complication than were patients in the control group (hazard ratio, 0.61; 95% confidence interval, 0.42 to 0.88). The number of patients needed to treat to prevent an anticoagulation therapy complication was 52. Additional analyses revealed that improved outcomes associated with CPAS were mediated largely through improved therapeutic INR control. Patients in the CPAS group spent 63.5% of study period days within their target INR range compared to 55.2% in the control group (p < 0.001). CONCLUSIONS: A centralized, telephonic, pharmacist-managed anticoagulation monitoring service reduced the risk of anticoagulation therapy-related complications compared to that with usual care. The cumulative evidence supporting the superior care associated with implementing a pharmacist-managed anticoagulation monitoring service was sufficient to recommend widespread implementation.     

Histopathologic pattern and clinical features of rheumatoid arthritis-associated interstitial lung disease

STUDY OBJECTIVES: To investigate the histopathologic pattern and clinical features of patients with rheumatoid arthritis (RA)-associated interstitial lung disease (ILD) according to the American Thoracic Society (ATS)/European Respiratory Society consensus classification of idiopathic interstitial pneumonia. DESIGN: Retrospective review. SETTING: Two thousand-bed, university-affiliated, tertiary referral center. PATIENTS: Eighteen patients with RA who underwent surgical lung biopsy (SLBx) for suspected ILD. METHOD: SLBx specimens were reviewed and reclassified by three lung pathologists according to the ATS/European Respiratory Society classification. Clinical features and follow-up courses for the usual interstitial pneumonia (UIP) pattern and the nonspecific interstitial pneumonia (NSIP) pattern were compared. RESULTS: The histopathologic patterns were diverse: 10 patients with the UIP pattern, 6 patients with the NSIP pattern, and 2 patients with inflammatory airway disease with the organizing pneumonia pattern. RA preceded ILD in the majority of patients (n = 12). In three patients, ILD preceded RA; in three patients, both conditions were diagnosed simultaneously. The majority (n = 13) of patients had a restrictive defect with or without low diffusion capacity of the lung for carbon monoxide (D(LCO)) on pulmonary function testing; 2 patients had only low (D(LCO)). The UIP and NSIP groups were significantly different in their male/female ratios (8/2 vs 0/6, respectively; p = 0.007) and smoking history (current/former or nonsmokers, 8/2 vs 0/6; p = 0.007). Many of the patients with the UIP pattern had typical high-resolution CT features of UIP. Five patients with the UIP pattern died, whereas no deaths occurred among patients with the NSIP pattern during median follow-up durations of 4.2 years and 3.7 years, respectively. CONCLUSIONS: The histopathologic type of RA-ILD was diverse; in our study population, the UIP pattern seemed to be more prevalent than the NSIP pattern.     

Outcomes of elderly survivors of intensive care: a review of the literature

An increasing proportion of critically ill patients are elderly (ie, >or= 65 years of age). This poses complex challenges and choices for the management of elderly patients. Outcome following admission to the ICU has been traditionally concerned with mortality. Beyond mortality, outcomes such as functional status and health-related quality of life (HRQOL) have assumed greater importance. This article reviews the literature, published in English from 1990 to December 2003, pertaining to HRQOL and functional status outcomes of elderly patients. Functional status and HRQOL of elderly survivors of ICUs has been underinvestigated. There is no agreement as to the optimal instrument choice, and differences between studies preclude meaningful comparison or pooling of results.     

Diagnostic classification of persistent rhinitis and its relationship to exhaled nitric oxide and asthma: a clinical study of a consecutive series of patients

BACKGROUND: Rhinitis and asthma represent the manifestation of one syndrome. Our hypothesis is that in patients with symptoms of persistent rhinitis, lower airway inflammation, lower respiratory symptoms, and lung function abnormalities compatible with asthma are more frequently associated with the diagnosis of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) than with nonallergic rhinitis (NAR). METHODS: One hundred eight of 590 consecutive patients referred in 1 year for rhinitis were enrolled on the basis of nasal symptoms lasting > 4 weeks. Asthma was diagnosed on the basis of symptoms and a positive bronchodilation testing result and/or methacholine hyperresponsiveness. Exhaled nitric oxide (Feno) was measured with the single exhalation method at 50 mL/s. RESULTS: AR was diagnosed in 39%, NAR in 21%, and CRS in 40%. The prevalence of asthma was significantly higher in AR patients (33%) and CRS patients (42%) than in NAR patients (8.7%) [p = 0.036 and p = 0.005, respectively]. Feno was significantly higher in patients with AR and CRS compared to patients with NAR (44.3 parts per billion [ppb]; 95% confidence interval [CI], 34 to 54 ppb; and 53 ppb; 95% CI, 42 to 64 ppb; vs 22 ppb; 95% CI, 18 to 27 ppb; p = 0.002 and p = 0.001, respectively). Patients with asthma had Feno values significantly higher than patients without asthma (64 ppb; 95% CI, 51 to 77 ppb; vs 33.3 ppb; 95% CI, 28 to 39 ppb; p < 0.001). CONCLUSIONS: The diagnostic classification of persistent rhinitis helps to predict lower airway inflammation (increased Feno) and prevalence of asthma: AR and CRS are associated with higher mean Feno values and higher prevalence of asthma than NAR.     

Predictors of survival in COPD patients with chronic hypercapnic respiratory failure receiving noninvasive home ventilation

BACKGROUND: Patients with COPD and chronic hypercapnic respiratory failure (CHRF) are at high risk, and noninvasive ventilation at home is increasingly being used. Knowledge of prognostic parameters under these conditions is limited but may be clinically helpful and highlight the role of noninvasive ventilation. METHODS: In 188 patients with COPD (mean +/- SD FEV1, 31.0 +/- 9.6% of predicted; PaCo2, 56.3 +/- 9.4 mm Hg) discharged from the hospital receiving NIV between July 1994 and July 2004, the prognostic value of body mass index (BMI), lung function, laboratory parameters, and blood gas levels was assessed by univariate and multivariate Cox regression analyses. Moreover, the impact of changes in risk factors on mortality assessed 6.7 +/- 2.8 months after the initiation of noninvasive ventilation was evaluated. RESULTS: Overall, the mortality rate during follow-up (duration, 32.2 +/- 24.3 months) was 44.7%, with 1-year, 2-year, and 5-year survival rates of 84.0%, 65.3%, and 26.4%. Deaths resulted predominantly from respiratory causes (73.8%). Univariate regression analyses revealed age, BMI, hemoglobin, FEV1, specific airway resistance, residual volume (RV)/total lung capacity (TLC), pH, and base excess (BE) to be associated with prognosis (p < 0.01 each), whereas multivariate analysis identified only age, BMI, RV/TLC, and BE as independent predictors (p < 0.05). In patients at risk (BMI < 25 km/m2, RV/TLC >or= 73%, or BE >or= 9 mmol/L), changes in these predictors were also associated with survival. CONCLUSIONS: In patients with COPD and CHRF, nutritional status, hyperinflation, and BE, which turned out to be reliable and consistent markers in CHRF, were independent prognostic factors for mortality. These data favor a multidimensional approach in these patients, including the use of noninvasive ventilation.