Accuracy of Nurse-Performed Lung Ultrasound in Patients With Acute Dyspnea: A Prospective Observational Study

In clinical practice lung ultrasound (LUS) is becoming an easy and reliable noninvasive tool for the evaluation of dyspnea. The aim of this study was to assess the accuracy of nurse-performed LUS, in particular, in the diagnosis of acute cardiogenic pulmonary congestion.We prospectively evaluated all the consecutive patients admitted for dyspnea in our Medicine Department between April and July 2014. At admission, serum brain natriuretic peptide (BNP) levels and LUS was performed by trained nurses blinded to clinical and laboratory data. The accuracy of nurse-performed LUS alone and combined with BNP for the diagnosis of acute cardiogenic dyspnea was calculated.Two hundred twenty-six patients (41.6% men, mean age 78.7 ± 12.7 years) were included in the study. Nurse-performed LUS alone had a sensitivity of 95.3% (95% CI: 92.6–98.1%), a specificity of 88.2% (95% CI: 84.0–92.4%), a positive predictive value of 87.9% (95% CI: 83.7–92.2%) and a negative predictive value of 95.5% (95% CI: 92.7–98.2%). The combination of nurse-performed LUS with BNP level (cut-off 400 pg/mL) resulted in a higher sensitivity (98.9%, 95% CI: 97.4–100%), negative predictive value (98.8%, 95% CI: 97.2–100%), and corresponding negative likelihood ratio (0.01, 95% CI: 0.0, 0.07).Nurse-performed LUS had a good accuracy in the diagnosis of acute cardiogenic dyspnea. Use of this technique in combination with BNP seems to be useful in ruling out cardiogenic dyspnea. Other studies are warranted to confirm our preliminary findings and to establish the role of this tool in other settings.     

The Outcome of Patients With 2 Different Protocols of Do-Not-Resuscitate Orders: An Observational Cohort Study

Lack of clarity about the exact clinical implications of do-not-resuscitate (DNR) has caused confusion that has been addressed repeatedly in the literature. To provide improved understanding about the portability of DNR and the medical care provided to DNR patients, the state of Ohio passed a Do-Not-Resuscitate Law in 1998, which clearly pointed out 2 different protocols of do-not-resuscitate: DNR comfort care (DNRCC) and DNR comfort care arrest (DNRCC-Arrest). The objective of this study was to examine the outcome of patients with the 2 different protocols of DNR orders.This is a retrospective observational study conducted in a medical intensive care unit (MICU) in a hospital located in Northeast Ohio. The medical records of the initial admissions to the MICU during data collection period were concurrently and retrospectively reviewed. The association between 2 variables was examined using Chi-squared test or Student''s t-test. The outcome of DNRCC, DNRCC-Arrest, and No-DNR patients were compared using multivariate logistic regression analysis.The total of 188 DNRCC-Arrest, 88 DNRCC, and 2051 No-DNR patients were included in this study. Compared with the No-DNR patients, the DNRCC (odds ratio = 20.77, P < 0.01) and DNRCC-Arrest (odds ratio = 3.69, P < 0.01) patients were more likely to die in the MICU. Furthermore, the odds of dying during MICU stay for DNRCC patients were 7.85 times significantly higher than that for DNRCC-Arrest patients (odds ratio = 7.85, P < 0.01).Given Do-Not-Resuscitate Law in Ohio, we examined the outcome of the 2 different protocols of DNR orders, and to compare with the conventional DNR orders. Similar to conventional DNR, DNDCC and DNRCC-Arrest were both associated with the increased risk of death. Patients with DNRCC were more likely to be associated with increased risk of death than those with DNRCC-Arrest.     

Tiotropium in Patients with Bronchiectasis: A Prospective Cohort Study

Purpose

There are limited studies on the use of bronchodilators for the treatment of bronchiectasis. This study investigated the efficacy of tiotropium in patients with bronchiectasis and airflow limitation.

Methods

This study was a prospective cohort study, including 169 patients with bronchiectasis and airflow limitation from 2015 to 2019. The clinical outcomes observed in our study were the effect of tiotropium on the frequency of moderate exacerbations, the time to the first severe exacerbation, and the annual decline in FEV₁.

Results

After 12 months, the annual decline in the FEV₁ after bronchodilator use was 27.08 ml or 42.9 ml per year in the group with or without tiotropium, respectively. Treatment with tiotropium was associated with a decreased risk of moderate exacerbation of bronchiectasis (Adjusted RR 0.618 95% CI 0.493–0.774; P?<?0.005). The time to the first severe acute exacerbation of bronchiectasis in the tiotropium group was longer than the non-tiotropium group (Adjusted HR 0.333 95% CI 0.219–0.506; P?<?0.001).

Conclusion

In conclusion, prospective cohort study showed that tiotropium effectively ameliorated the annual decline in the FEV_1, with a lower-risk rate of moderate exacerbations and prolonging the time to the first-time severe exacerbation in patients with bronchiectasis and airflow limitation.

     

Proprotein Convertase Subtilisin/Kexin type 9, C-Reactive Protein,Coronary Severity,and Outcomes in Patients With Stable Coronary Artery Disease: A Prospective Observational Cohort Study

Proprotein convertase subtilisin/kexin type 9 (PCSK9) is suggested as a novel factor associated with coronary artery disease (CAD). However, few studies have comprehensively evaluated plasma PCSK9 with cardiovascular risk till now. Hence, we aimed to prospectively investigate the association between baseline PCSK9 and cardiovascular risk graded with number of risk factors (RFs), coronary severity, and outcomes in patients with stable CAD.Baseline characteristics and biomarkers were measured in 616 consecutive, nontreated patients with stable CAD. Coronary severity was measured using SYNTAX, Gensini, and Jeopardy scoring systems. Patients were then received treatment and followed for a median of 17 months. The primary endpoints were cardiac death, stroke, myocardial infarction (MI), post-discharge revascularization, or unstable angina (UA).Overall, follow-up data were obtained from 603 patients. A total of 72 (11.9%) patients presented with at least 1 major adverse cardiovascular event (MACE) (4 cardiac deaths, 4 strokes, 6 MIs, 28 revascularizations, and 30 UAs). At baseline, PCSK9 was increased with an increasing number of RFs and positively associated with coronary severity scores (P < 0.05, all). After follow-up, those with MACE had a higher baseline PCSK9, hs-CRP, and coronary scores than those without (P < 0.05, all). Multivariate analysis showed that PCSK9, hs-CRP, and coronary scores were independently predictive for MACEs (P < 0.05, all). Interestingly, more significant predictive values of PCSK9 in medical-alone-treated population but no such associations in revascularization-treated patients were found.Together, plasma PCSK9, as well as hs-CRP and coronary scores, could independently predict MACEs in patients with stable CAD.     

Predicting Emergency Department Utilization in Adults with Asthma: A Cohort Study

A consecutive sample of 378 adults with asthma were assessed at a university asthma program and then interviewed 1 year later regarding their need for emergency department (E.D.) asthma treatment. The purpose of this prospective cohort study was to determine whether any of their initial features could predict their subsequent need for E.D. asthma treatment. At one year, a total of 73 of the subjects had attended emergency departments for asthma. On entry, the 73 subjects had demonstrated more self-reported lifestyle restriction from asthma and more hospital admissions E.D. visits for asthma as well as poorer asthma control or than had the 305 subjects who had not required E.D. asthma treatment since entry to the cohort. This study suggests that special attention should be paid to subjects with asthma that interferes with their lifestyle and to those who have needed hospital admission for asthma.